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TEXT-BOOK 



OF 



HYGIENE 

A Comprehensive Treatise on the Principles and 

Practice of Preventive Medicine from an 

American Standpoint 



GEORGE H. ROHE, M.D. 

M 

Late Professor of Therapeutics. Hygiene, ano Mental Diseases in the College of 
Physicians and Surgeons, Baltimore, Etc. 



ALBERT ROBIN, M.D. 

Professor of Pathology. Bacteriology and Hygiene, Medical Department Temple University, 
and Philadelphia Dental College; Bacteriologist City Water Department. Wilmington, 
Delaware; Member American Public Health Association, Society American 
Bacteriologists; Corresponding Member International Society for 
the Prevention of Tuberculosis, etc. ; Formerly Patholo- 
gist and Bacteriologist Delaware State 
Board of Health. 



FOURTH REVISED AND ENLARGED EDITION 
With Many Illustrations and Valuable Tables 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 

1908 




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^.IBSTARY of CONGRESS 

two Oooies Kecw.t*? 

OCT i *aoa 

CO FY a. 



COPYRIGHT 1891, 

BY 

F. A. DAVIS 
COPYRIGHT, 1894, 

BY 

THE F. A. DAVIS COMPANY 
COPYRIGHT, September, 1908, 

BY 

F. A. DAVIS COMPANY 

[Registered at Stationers' Hall, London, England] 



Philadelphia, Pa., U. S. A. : 

Press of F. A. Davis Company 

1914-16 Cherry Street. 



PREFACE TO THE FOURTH EDITION. 



The advances made in hygiene and sanitary science, more espe- 
cially in the field of causation and prevention of infectious diseases, 
made it necessary to subject this well-known and popular text-book to 
a thorough revision. Several of the chapters treating of subjects in 
which the discoveries were more recent were entirely rewritten, while 
others were brought up-to-date by including such matter as appeared 
essential in the light of recent advances. 

The aim of the editor has been to preserve in the book the 
qualities which made it one of the most popular text-books on hygiene 
in the English language. 

As no one man can be a specialist in all branches of hygiene and 
sanitation, it was necessary to secure the assistance of other men. 
This had been done by the author in the former editions of this book, 
and the plan has been followed by the editor in the present edition, 
with this exception, however: in the present edition credit to the 
several eminent contributors is given here in the preface. 

Dr. Walter Wyman, Supervising Surgeon-General, U. S. Public 
Health and Marine-Hospital Service, has revised the chapter on 
"Quarantine." The chapters on "School Hygiene," "Exercise and 
Training," "Baths and Bathing," and "Clothing," grouped together 
with one chapter heading "Personal Hygiene," were prepared by 
Dr. Francis W. Upshur, lecturer on pathology, hygiene, public health 
and dietetics in the University College of Medicine, Eichmond, Vir- 
ginia. The chapter on "Military and Camp Hygiene" was entirely 
rewritten throughout by Walter D. McCaw, Surgeon-Major, Medical 
Department, Surgeon-General's Office, Washington, D. C. The chap- 
ter on "Naval Hygiene" also was entirely rewritten by Henry G. 
Beyer, Major Surgeon United States Navy and professor of hygiene, 
etc., in the United States Army and Navy Medical School, Washing- 
ton, D. C. 

The other chapters were revised and supplemented by the editor. 
It is hoped that this edition will be favored with the same cordial 
reception accorded to former editions by students and teachers 
throughout the country. 

A. Eobin. 
Wilmington, Del. 

(in) 



PREFACE TO THE THIRD EDITION. 



In this edition every chapter has been subjected to a careful 
revision, and the advances in sanitary science and practice have been 
incorporated. 

Recent legislation in the United States and Canada has almost 
revolutionized quarantine practice. Surgeon-General Walter Wyman, 
and Dr. H. D. Geddings, of the United States Marine-Hospital Serv- 
ice, have, at the request of the author, entirely rewritten the chapter 
upon "Quarantine," and it will be found to represent fully the modern 
principles and practice of maritime sanitation. 

Medical Director Albert L. Gihon, United States Navy, has again 
thoroughly revised the chapter on "Marine Hygiene." 

With the view of making the book still more useful to teachers, 
students, and sanitary officers than heretofore, an analytical set of 
questions has been appended to each chapter, and a separate section 
has been added on methods of examination of air, water, and food. 
For these additions the author is indebted to Professor Seneca Egbert, 
of Philadelphia. Dr. Egbert has also carefully revised the chapter on 
"Vital Statistics." 

The author desires to thank all who have assisted him in the 
work, and especially the sanitarians throughout the country who have 
been helpful in the way of criticism and suggestion. He hopes that 
the new edition will merit, as well as receive, the approval of all 
students of preventive medicine. 

G. H. E. 
Balximobe, Md. 



(iv) 



PREFACE TO THE FIRST EDITION. 



The aim of the author in writing this book has been to place in 
the hands of the American student, practitioner, and sanitary officer, 
a trustworthy guide to the principles and practice of preventive medi- 
cine. 

He has endeavored to gather within its covers the essential facts 
upon which the art of preserving health is based, and to present these 
to the reader in clear and easily understood language. 

The author cannot natter himself that much in the volume is 
new. He hopes nothing in it is untrue. 

G. H. E. 



(v) 



CONTENTS. 



Chapter Page 

I.— Air 1 

II.— Water 46 

III.— Food 110 

IV.— Soil 160 

V. — Eemoval of Sewage 172 

VI. — Construction of Habitations 192 

VII. — Construction of Hospitals 219 

VIII.— School Hygiene 229 

IX. — Industrial Hygiene 246 

X. — Military and Camp Hygiene 268 

XI. — Marine Hygiene 285 

XII.— Prison Hygiene 348 

XIII.— Personal Hygiene 353 

XIV.— Disposal of the Dead 369 

XV.— The Germ Theory of Disease 374 

XVI. — Contagion and Infection 385 

XVII. — History of Epidemic Diseases 391 

XVIII. — Antiseptics, Disinfectants and Deodorants 447 

XIX.— Altai Statistics . . : , 462 

XX. — Quarantine 472 

Index 567 



(vii) 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Organic Matters Frequently Present in Dust 32 

2. Air-tester 34 

3. Showing Formation of Spring 55 

4. Plans of 30,000,000-Gallon Storage Reservoir 82 

5. Plans of Intake and Water Tower Used in Connection with the 

Reservoir 83 

6. Plans of Slow Sand Filters 85 

7. Showing Interior of Filter Recently Constructed in Washington, D. C. . 89 

8. Showing Exact Size of Filtering Material Used in Construction of 

Sand Filters 92 

9. Showing Interior of Mechanical Filter 92 

10. Chevallier's Creamometer 124 

11. Pull-up Handle Commode 177 

12. Showing the Apparatus Mounted on Bearers as when Fixed 177 

13. Dry Closet 178 

14. Bury Ventilator in Operation. Inside View 201 

15. Bury Ventilator in Operation, Outside View 201 

16. Ventilation of a Room Containing an Open Fireplace 202 

17. The "Dececo" Closet (New Form) . . % 207 

18. The "A. G. M." Closet 208 

19. Sectional View of "A. G. M." Closet 209 

20. Flushing Cistern for Water-closets 211 

21. S-Trap 212 

22. Sectional View of Vent, with Cap in Normal Position 213 

23. Sectional View of Vent, with Cap Lifted Out of the Mercury by the 

Inflowing Current of Air 213 

24. Connolly Globe-trap 214 

25. Globe-trap Attached to Basin 214 

26. Plan of Johns Hopkins Hospital 221 

27. Bury Ventilator for Use in School-rooms, Inside View 231 

28. Bury Ventilator for Use in School-rooms, Outside View 231 

29. Adjustable School-deck (Front View) 234 

30. Myopia According to School-classes — Boys 236 

31. Myopia According to School-classes — Girls 237 

32. Showing Influence of a High Desk in Causing Spinal Curvature .... 239 

33. Cross-section of Ship, Showing Arrangement of Drainage System . . . 299 

34. Showing Arrangement of Deck-planking 302 

35. Showing Location of Limber Holes 303 

36. Showing Location of Bilge-space in Modern Iron Ship 304 

37. Showing Location of Bilge-space on Top of Double Bottom 305 

38. Showing Plan of Large Modern Battleship 315 

39. Distilling Plant as Installed in Vessels of the United States Navy . . 333 

40. 41, 42 Plans Showing Arrangement of Ventilation on the Idaho and 

Mississippi 342 

43. Forms of Bacteria ( From Schenk) 375 

44. Spirochaeta Obermeieri, X 380 419 

45. Pure Culture of Typhoid Bacilli, Showing Clumping when Brought in 

Contact with Blood from Typhoid Patients, (Widal reaction) . . . 421 

46. Diphtheria Bacilli {Park) . . . . 427 

47. Micrococci Gonorrhea in Pus {Park ) 433 

48. Actinomyces Hominis {Lung) , X 350 435 

49. Colony of Anthrax Bacilli, siightlv Magnified, (After Fliigge) 436 

50. Bacillus Mallei {Park) * 437 

(viii) 



Text-Book or Hygiene. 



CHAPTER I. 



AIR. 

Exact investigation into the influence of the atmosphere upon 
health is yet in its infancy. Enough has been learned, however, to 
show that changes in the composition of the air, in its density, its tem- 
perature, its humidity, its rate and direction of motion, and possibly 
its electrical or magnetic conditions, influence in various ways the 
health of the individual. It is only very recently that any scientific 
attempts have been made to trace the bearing of atmospheric changes 
upon health. The observations already recorded indicate that a 
thorough study of meteorological phenomena in connection with the 
origin and progress of certain diseases is a promising field of labor 
for the educated sanitarian. The meteorological observations which 
have been gathered by the United States Signal Service, together 
with elaborate studies made by the meteorologists and climatologists 
of other countries, already form such a large and tolerably complete 
and well-arranged body of facts, that reasonably accurate deductions 
can even now be made. Heretofore, in studying the sanitary relations 
of the atmosphere, both in this country and abroad, the attention 
of observers has been riveted almost exclusively upon the changes 
in its composition occurring within certain limited areas. It is, 
perhaps, equally important to study this universally diffused and 
necessary condition of vital activity in its broader and more general 
relations. It will be shown, in the course of the present work, that 
the meteorological features of countries, or of seasons, or even the 
daily atmospheric changes, exercise an important influence upon life 
and health. In order to fully appreciate these relations it will be 
necessary to first give a brief summary of the facts and laws of 
meteorology. 

(i) 



2 TEXT-BOOK OF 11VCI EN I \ 

THE COMPOSITION AND PHYSICAL CONDITIONS OF THE 
ATMOSPHERE. 

Atmospheric air has the following composition : — 

Oxygen 20.91 per cent. 

Nitrogen 77.95 " 

Argon 1.00 

Carbonic acid 0.04 

Aqueous vapor variable. 

Traces of organic matter, ozone, mineral salts, ammonia, nitric acid, 
krypton, neon, metargon, carburetted hydrogen. 

These proportions are maintained, with but very little change, 
at different heights. At first thought, it would seem that carbon 
dioxide, being much heavier than the other constituents of air, would 
accumulate in the lower regions of the atmosphere, and there cause 
an excess of this poisonous constituent ; but in obedience to the law of 
diffusion the intermingling of the component gases is perfect, and 
the proportion of carbon dioxide in the atmosphere is quite as great on 
mountain-tops as in the deepest valleys. This diffusion of gases, 
however, is modified by the wind and, in cities, by high buildings. 

The proportion of nitrogen in atmospheric air is generally uni- 
form, while that of oxygen varies, depending to a great extent upon 
the amount of carbon dioxide present. Hence, an increase in the 
amount of the latter constituent is usually accompanied by a diminu- 
tion of oxygen, inasmuch as the formation of carbon dioxide can only 
take place at the expense of oxygen. The reciprocal activities of ani- 
mal and vegetable life are beautifully illustrated hy these relations 
between the oxygen and carbon dioxide in the air. In the processes 
of combustion and oxidation, oxygen is withdrawn from the atmos- 
phere, and combines with carbon, forming carbon dioxide. During 
vegetable growth, on the other hand, carbon dioxide is withdrawn 
from the air by the leaves of plants, and decomposed into its ele- 
ments, carbon and oxygen. The carbon is used in building up the 
plant, while the liberated oxygen is restored to the atmosphere. The 
animal consumes oxygen, and gives out carbon dioxide; the plant 
resolves this compound into its constituent elements, and gives back 
the oxygen to the air. However, at night, or in the absence of sun- 
light, plants evolve carbon dioxide instead of oxygen, and for this 
reason it is injurious to keep plants in bedrooms over night. 

The atmosphere extends upward from the surface of the earth 
to an indefinite distance. The limit has been variously placed at 
from 75 kilometres to 40,000 kilometres. For all sanitary purposes 



COMPOSITION AND CONDITIONS OF ATMOSPHERE. 3 

the former may be taken as the upward limit of the atmosphere. In 
obedience to the law of gravity, this mass of air presses everywhere 
directly downward — toward the earth's centre — with a force equal 
to its weight. If a column of this air be balanced by a column or 
mass of any other matter — the columns being of the same diameter — 
we have a relative measure of the weight of the atmosphere. The 
instrument with which the weight or downward pressure of the air 
is measured is called a barometer. The atmosphere, at the sea-level, 
presses downward with a force equal to the pressure of a column of 
mercury 7G0 millimetres high. Hence, the barometric pressure at 
sea-level is said to be 760 millimetres, or 30 inches. If the barometer 
be carried to the summit of a mountain 1000 metres above the level 
of the sea, or be taken to the same altitude in a balloon, the mercury 
in the barometer-tube will fall about 90 millimetres. These 90 
millimetres of the mercurial column represent the weight of 1000 
metres of air now below the barometer, and consequently not meas- 
ured or balanced by it. 1 

Upon ascending from the sea-level, it is found also that the 
air, being less pressed upon by that which is still above it, becomes 
more rarefied and lighter ; its tension, as it is termed, is less. Hence, 
for the second 1000 metres of ascent above the sea, the mercury will 
fall a less distance in the tube, the weight removed not being so great 
as in the first 1000 metres. 

The following table shows the diminution in atmospheric pres- 
sure for every 1000 metres above sea-level: — 



Sea-lev 

1,000 

2,000 

3,000 

4,000 

5,000 

6,000 

7,000 

8,000 

9,000 

10,000 

11,000 

12,000 

15,000 

20,000 



Table I. 

el 760.0 millimetres. 

metres 670.4 

591.5 

521.0 

460.3 

406.0 

358.2 

316.0 

278.8 



245.9 
216.9 
191.1 
168.8 
115.9 
61.9 



1 The figures here given are not absolute, but merely approximate. The 
limits of this work do not allow a full discussion of the meteorological ele- 
ments modifying the pressure of the atmosphere at sea-level. 



4 TEXT-BOOK OF HYGIENE. 

Variations in temperature and humidity of the air influence the 
tension of the atmosphere in a marked degree, and affect the height 
of the barometric column. In fact, most of the changes of atmos- 
pheric pressure at the surface of the earth are directly due to changes 
in temperature and humidity. Increase of temperature diminishes 
the density of the air. Hence, when the temperature rises the pres- 
sure decreases. 

The proportion of moisture (aqueous vapor), if increased, like- 
wise causes a diminution in pressure. It is found, for example, that 
when the amount of aqueous vapor in the air increases, the barometer 
falls. This is due to the fact that the specific gravity of aqueous vapor 
is less than that of dry air, being in the proportion of .623 to 1.000. 
Hence, as aqueous vapor is diffused through the air, the latter becomes 
lighter, — or, in other words, the barometric pressure diminishes. 

The warmth of the air is primarily derived from the sun. On 
a clear day about one-fourth of the heat of the sun's rays is given 
off directly to the air during the passage of the heat-rays to the earth. 
Of the remaining three-fourths, part is reflected from the earth, 
while the larger portion is first absorbed by the earth and then given 
off by radiation and convection to the superincumbent air. 

The air is always warmer near the earth's surface on a clear, 
sun-shiny day; for, as soon as the earth gets warmer than the air 
immediately above it, the excess of heat is given off to the latter by 
convection and radiation. On ascending from the surface of the 
earth the temperature decreases, and on the summit of a high moun- 
tain the air is always colder than at its base. The decrease of tem- 
perature with the ascent equals 1° F. to every 300 feet. 

Professor Tyndall has shown that dry air absorbs less heat than 
air which is charged with vapor. For this reason the sun's rays strike 
the earth with much greater intensity on a very dry than on a moist 
day, while on the latter a larger proportion of the heat-rays is inter- 
cepted before they reach the earth. 

Recent experiments seem to show, however, that the difference 
in diathermancy between dry and humid air is not so great as sup- 
posed by Tyndall. The depth of the air-stratum, through which the 
sun's rays pass, is of greater influence than the humidity. 

Air, at different temperatures, is capable of absorbing different 
amounts of aqueous vapor. Thus, air at a temperature of 4° will 
require a much smaller amount of vapor to produce saturation than 
air at a temperature of 30°. For this reason air which appears 
"damp" at the former temperature, both to the bodily sensations and 



COMPOSITION AND CONDITIONS OF ATMOSPHERE. 

to appropriate instruments, would be considered as "dry" at the latter 
temperature, although the actual amount of vapor present, or absolute 
humidity, is the same in both cases. 2 In meteorological observations 
for sanitary purposes, the relative humidity is the condition deserving 
especially careful study. 

It must be borne in mind that the mere statement of the per- 
centage of relative humidity, without taking into account the tem- 
perature of the air, is of little significance. A like remark is justi- 
fied with regard to statements of absolute humidity, when used to 
illustrate the apparent effects of atmospheric moisture upon life and 
health. 

The following table shows the absolute humidity correspond- 
ing to the same relative humidity at different temperatures. It also 
includes the total possible absolute humidity and the difference be- 
tween the actual and possible humidity (deficiency of saturation) at 
the temperatures given: — 

Table II. 



Tempera- 
ture °C. 


Relative 
Humidity 
(per cent.). 


Absolute Humidity 
(grammes per 
cubic metre). 


Greatest Possible 
Absolute Humidity. 


Deficiency of 
Saturation. 


—20 

—10 


+10 
20 
30 


60 
60 
60 
60 
60 
60 


0.638 
1.380 
2.924 
5.623 
10.298 
18.083 


1.064 
2.300 
4.874 
9.372 
17.164 
30.139 


0.426 
0.920 
1.950 
3.749 
6.866 
12.056 



In forests the relative humidity is usually higher than over un- 
wooded districts, although the absolute humidity may be the same, 
or, perhaps, even less. The evaporation is usually much greater in 
the open air than in forests. In closed apartments the evaporation 
may be greater or less than in the open air, depending upon the 
local conditions present. 



2 By "absolute humidity" is meant the total amount of vapor present 
in a certain mass of air. By the term "relative humidity" meteorologists 
designate the proportion of vapor present at certain temperatures, compared 
with full saturation of the air with vapor, which is reckoned 100. Thus, air 
which is saturated, or whose relative humidity is 100 at 4°, would have a 
relative humidity of only 24, if the temperature were raised to 27°, because 
jn the latter case the capacity of the air for aqueous vapor is increased. 
Relative humidity is always designated in percentages; absolute humidity in 
grammes per cubic metre or grains per cubic foot. 



6 TEXT-BOOK OF HYGIENE. 

The motion of the air — wind — is caused by differences in 
presssure; the latter being due to differences in temperature and 
humidity. A mass of air traversing a large body of water absorbs 
vapor, unices already saturated, and becomes moist; if it pass over 
a wide tract of dry land it loses moisture and becomes dry. There- 
fore in the eastern portion of the American continent, an easterly 
or southerly wind, which comes from over large bodies of water, and 
which is usually warm, and thus capable of holding a large quantity 
of water in a state of vapor, is always moist. On the other hand, a 
northerly or westerly wind, coming over a large extent of dry land, 
and from a colder region, is nearly always a dry wind. On the 
Pacific coast these conditions are reversed; there a westerly wind is 
a moist wind, while an easterly wind is dry. The dreaded easterly 
wind of England is likewise a dry wind. It is probable that the 
direction and rate of motion of air-currents have considerable in- 
fluence upon the origin or intensification of certain diseases. 

The electrical and magnetic conditions of the atmosphere have 
been as jet studied to little advantage. It is only known that atmos- 
pheric electricity is, in most cases, positive, and that its intensity in- 
creases with condensation of vapor. There seems to be no doubt that 
the varying states of atmospheric electricity are closely connected with 
evaporation and condensation. There is reason to believe that a 
fuller knowledge on these topics will yield most important results 
to the student of hygiene. 

Ozone, which is oxygen in an allotropic and highly active con- 
dition (0 3 ), is generally absent from town air; and when it does 
appear, as after a summer storm, it is in such insignificant amount 
as to have no influence on health. 



BACTERIA IN THE AIR. 

In localities which are free from human or animal habitation, 
as in open plains, high moutains, midocean, etc., the air is free from 
bacteria; on the other hand, bacteria will be present wherever man 
or animal abides. The number of bacteria will be in direct proportion 
to the density of the population, the larger number being found in 
cities, and, again, in the overcrowded portions of the large centres 
of population. Defective sanitation will increase the number of bac- 
teria. In addition to bacteria, the air contains yeasts and the spores 
of moulds and of the lower fungi. The moulds are provided with 
fine spore-bearing filaments, which become detached and float in a 



INFLUENCE OF ATMOSPHERIC PRESSURE. 7 

free condition. The bacteria, on the other hand, do not float, but are 
carried by particles of dust or moisture. The epoch-making experi- 
ments of Pasteur and Tyndall have demonstrated, the axiomatic 
proposition that without dust there are no bacteria. Consequently, 
any disturbance which raises dust will also increase the number of 
bacteria in the air, and, conversely, any agent which allays dust also 
purifies the air. It is for this reason that the use of a damp cloth 
is preferable to dusting, and a carpet-sweeper is more sanitary than a 
broom. The bacteria present in the air may be of three kinds: 
(1) Harmless bacteria; (2) bacteria which produce putrefaction; 
and (3) bacteria which cause disease. The latter are the most im- 
portant and are derived from sick persons. The actions of cough- 
ing, sneezing, speaking, and even of deep breathing distribute min- 
ute droplets of secretions from the respiratory passages and thus 
infect the atmosphere. Diphtheria, influenza, pneumonia, whooping 
cough, tuberculosis, and other infections of the respiratory organs 
may be and are communicated in this way. The fine particles of the 
bacteria-laden secretions may be directly inhaled by the person 
standing in front of the mouth of the patient, or else they fall to 
the ground, dry out, and dry bacteria are carried by the dust into 
the air. It is in this way that the sputum from consumptives be- 
comes a serious and constant source of infection. In eruptive fevers, 
like measles, scarlet fever, small-pox, etc., the causative agent, still 
unknown, is eliminated through the skin and carried into the air 
by the fine particles of dry epithelium. The bacilli of t3'phoid fever 
and cholera may also find their way into the air through the drying 
of infected sewage or water, or the excreta from the patient may be- 
come mixed with dust, and, when dry, be carried into the air and 
subsequently deposited in water, milk, or other food. That infection 
by this method is not more frequent is due to the fact that many 
pathogenic bacteria are destroyed by drying and sun-light. 

INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE 
ON HEALTH. 

The effects of a considerable diminution of pressure are familiar 
to every one in the "mountain sickness" which attacks most persons 
on ascending high mountains. M. Bert has shown experimentally 
that similar effects can be produced in an air-tight chamber by 
diminishing the pressure. The symptoms produced under a pres- 
sure equivalent to an altitude of from 4000 metres to 5000 metres 



8 TEXT-BOOK OF HYGIENE. 

were a feeling of heaviness, nausea, ocular fatigue, rapidity of pulse, 
convulsive trembling on slight exertion, and a sensation of languor 
and general indifference to the surroundings of the individual. 

M. Lortet, who has left on record his experiences in the higher 
Alps, says that the symptoms noticed on ascending to high altitudes 
are: Labored respiration, increased rapidity of pulse, depression of 
temperature (as much as 4° to 7° C). The normal temperature 
was restored, however, after a brief rest. Still more severe symp- 
toms have been noticed on ascending high mountains in South 
America and Asia. Aeronauts have lost consciousness, and in several 
instances life, on rapidly ascending to great altitudes. 3 According to 
the observations of the brothers Schlagintweit, distinguished ex- 
plorers of the highlands of Asia, the effects of diminished pressure 
upon the human organism are: "Headache, difficulty of respiration, 
and affections of the lungs, — the latter even proceeding so far as to 
occasion blood-spitting, — want of appetite, and even nausea, muscular 
weakness, and a general depression and lowness of spirits. All these 
symptoms, however, disappear in a healthy . man almost simul- 
taneously with his return to lower regions." A singular observation 
was made by these travelers on the effect of motion of the air upon 
the S3 T mptoms described. They say: "The effects here mentioned 
were not sensibly increased by cold, but the wind had a most decided 
influence for the worse upon the feelings. . . . When occupied 
with observations, we took. very little, if any, bodily exercise, some- 
times for thirty-six hours; it would frequently occur nevertheless, 
even in heights not reaching 17,000 feet (about 5150 metres), that 
an afternoon or evening wind would make us all so sick as to take 
away every inclination for food. No dinner was cooked; the next 
morning, when the wind had subsided, the appetite was better. 

"The effects of diminished pressure are considerably aggravated 
by fatigue. It is surprising to what degree it is possible for ex- 
haustion to supervene ; even the act of speaking is -felt to be a labor, 
and one gets as careless of comfort as of danger. Many a time our 
people — those who ought to have served us as guides — would throw 
themselves down upon the snow, declaring they would rather die 
upon the spot than proceed a step farther." 4 



3 MM. Sivel and CrocC-Spinelli, two aeronauts, lost their lives in this 
manner during an ascent from Paris, in April, 1875. 

4 Results of a Scientific Mission to India and High Asia. By Hermann, 
Adolphe, and Robert De Schlagintweit, vol. ii, pp. 484, 485. 



INFLUENCE OF ATMOSPHERIC PRESSURE. 9 

These symptoms disappear when persons are exposed to these 
conditions for a prolonged time. Thus, in the Andes there are places 
4000 metres above sea-level which are permanently inhabited; and 
in the Himalayas there are villages at a height of over 5000 metres 
constantly occupied. In this country, Pike's Peak, 4350 metres 
above the sea, has been occupied since 1873 by observers of the signal 
service. The men seem to become acclimated, as it were, and suffer 
little or no inconvenience from the diminished pressure after a time. 

The minor- disturbances of healthy function produced by dimin- 
ished pressure (within the limits of 4000 metres altitude, or 460 milli- 
metres barometric pressure) are an increase in the pulse and respira- 
tion rate. This is probably due to the struggle of the organism to 
take up the required quantity of oxygen, which is reduced in propor- 
tion by the rarefaction of the air. For example, the proportion of 
oxygen at a pressure of 460 millimetres wouM be equivalent to 12.6 
per cent, at sea-level, instead of the normal 20.9 per cent. 

Paul Bert has shown by personal experiments in the pneumatic 
chamber that the increase in pulse and respiration rate is not due to 
the merely mechanical diminution of pressure, but to the deficiency 
of oxygen. Hence the physiological effects of high altitudes upon 
circulation and respiration are not purely physical, due to dimin- 
ished pressure, but vital, and depend upon the change in the chemical 
composition of the atmosphere. The simple diminution of oxygen 
without reduction of pressure will produce similar though not identi- 
cal effects upon the organism. 

Above the height of- 4000 metres above sea-level (below 460 
millimetres pressure) the profounder disturbances of function char- 
acterized as "mountain sickness" come on. Different individuals re- 
act in different degree to the morbific influences of greatly dimin- 
ished atmospheric pressure (and coincident reduction of oxygen). 
Thus Glaisher reached an elevation of 11,000 metres (191.1 milli- 
metres pressure) and returned to the earth alive, while Croce- 
Spinelli and Sivel perished at the considerably lower elevation of 
8000 metres, equivalent to a pressure of 260 millimetres (7.2 per 
cent, of oxygen). 

The sanitarian is most concerned about the effects of pressure of 
the atmosphere from 760 millimetres down to 460 millimetres (or up 
to an altitude of 4000 metres above sea-level). The climatotherapy 
of various diseases requires that the effects of variations of pressure 
between these limits should be carefully studied, The observations 



10 TEXT-BOOK OF HYGIENE. 

of Mermod and Jourdanet 5 have illustrated the common physiological 
effects of these circumscribed changes, while the experiences of 
therapeutists have established the fact very clearly that many cases 
of phthisis improve markedly in a rarefied atmosphere, provided, how- 
ever, they are not subject to hemorrhages, in which case high altitude 
increases the liability to hemoptysis. Other obsarvers have also 
shown that the effects of diminished pressure are not always bene- 
ficial, and Dr. Loomis has warned against the sending of patients 
with heart disease to high altitudes. Whether the lethal effects that 
have been recorded in such cases are due to the increased activity of 
the heart and heightened blood-pressure from deficient oxygen, or as 
suggested by Dr. F. Donaldson, Jr., to dilatation of the heart-walls 
from diminution of external pressure, is as yet unsettled. 6 

It is probable that the diurnal or accidental 7 oscillations of 
barometric pressure at sea-level have no appreciable influence upon 
the organism. The statement is occasionally met that patients sub- 
jected to grave surgical operations often do badly during low at- 
mospheric pressure, and some surgeons never operate when the 
barometer is low or falling if they can avoid it. An inquiry under- 
taken by the writer in 1876, in which the excellent records of the 
Massachusetts General Hospital and the observations of the Boston 
station of the United States Signal Service for five years were used 
as the basis of comparison, resulted negatively. The deaths follow- 
ing operations done on days when the barometer was high' or rising 
were exactly equal in number to those following operations when the 
barometer was low or falling. Unfortunately, the investigation was 
never pursued to the extent of including other meteorological ele- 
ments, such as humidity, cloudiness, precipitation, etc. The numer- 
ous studies of the relations of variations of pressure to the progress 
of infectious diseases have also failed to yield any fruits of value. 
^Yhether the nerve-pains so frequently complained of, especially by 
elderly patients, during the progress of areas of low barometer, are 
due to the diminished pressure, or to the influence of some other 
meteorological factor, such as humidity or electrical condition, can- 
not yet be decided. 



5 Jourdanet states that while the French and Belgian soldiers in Mexico 
had an accelerated pulse, the natives had a normal pulse. In Mermod's ob- 
servations the average frequency of the pulse at St. Croix (1106 metres above 
sea-level) was nearly four beats greater than at Strassburgh (142 metres). 
The condition of the natives at the high settlements of the Andes and Hima- 
layas has not yet been investigated with exactitude. 

6 American Climatological Association, 1887. 

1 Meaning the oscillation produced by storm waves. 



INFLUENCE OF TEMPERATURE ON HEALTH. H 

Increased atmospheric pressure, as noticed in caissons, tunnels, 
and mines, produces increase in frequency and depth of respiration, 
diminution in the number of beats and volume of the pulse, pallor 
of the skin, increase of perspiration "(although Smith states that 
this is only apparent and due to lack of evaporation from the sur- 
face), increased appetite, and more abundant excretion from the 
kidneys. 

Among the distinctly pathological effects of increased atmos- 
pheric pressure , are rupture of the drum of the ear, pain in the frontal 
and maxillary sinuses, neuralgic pains, nausea, sometimes vomiting, 
and local paralyses. Dr. A. H. Smith 8 defines this collection of 
symptoms as "The Caisson Disease," and gives the following sum- 
mary of its characteristic features: — 

"A disease depending upon increased atmospheric pressure, but 
always developed after the pressure is removed. It is character- 
ized by extreme pain in one or more of the extremities, and some- 
times in the trunk, and which may or may not be associated with 
epigastric pain and vomiting. In some cases the pain is accompanied 
by paralysis more or less complete, which may be general or local, 
but is most frequently confined to the lower half of the body. Cere- 
bral symptoms, such as headache and vertigo, are sometimes present. 
The above symptoms are connected, at least in the fatal cases, with 
congestion of the brain and spinal cord, often resulting in serous 
or sanguineous effusion, and with congestion of most of the abdominal 
viscera." 

The measures to be adopted in preventing "Caisson Disease" 
are: (1) Working during short shifts, from 2 to 4 hours; (2) 
abundant supply of fresh air; (3) the use of electric light, so as to 
save the oxygen; (4) slow decompression, at the rate of one minute 
for every three pounds of pressure. The disregard of the last rule 
has recently caused several deaths among laborers working in the 
tunnels under the Hudson Eiver. 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 

Many of the derangements of health ascribed to high tempera- 
ture are to a considerable degree due to other factors, prominent 
among which are high humidity, intemperance, overwork, and over- 
crowding. There can be little doubt, however, that the importance 



8 The Physiological, Pathological, and Therapeutical Effects of Com- 
pressed Air, p. 47, Detroit, 1886. 



12 TEXT-BOOK OF HYGIENE. 

of the high temperature itself can hardly be overrated. It has been 
generally accepted heretofore that a high temperature, together with 
a high relative humidity, is most likely to be followed by sun-stroke. 
A careful comparison ^in a series of deaths from sun-stroke in the 
city of Cincinnati in the summer of 1881 shows, however, conclu- 
sively that a very high mean temperature with a low relative humidity 
is more liable to be followed by sun-stroke than the high tempera- 
ture when accompanied by a high humidity. The same series of ob- 
servations also shows that the number of deaths was greater on clear 
days than on cloudy or partly cloudy days. 9 A corroboration of this 
result is found in the fact that sun-strokes very rarely occur on ship- 
board, at sea, where the relative humidity is always high. 

The direct influence of the sun's rays upon the skin produces at 
times an erythematous affection which may run into a dermatitis if 
the insolation is prolonged. Artificial heat may produce similar 
effects. 

The prevention of sun-stroke should include the wearing of light 
and loosely-girded clothing, so as to favor the rapid evaporation of 
perspiration ; the use of cool, but not ice-cold water ; total abstinence 
from alcoholic beverages; and the maintenance of the functions of 
the alimentary canal in a healthy condition. Constipation should be 
particularly guarded against. Severe muscular exertion should be 
avoided during the hottest part of the day. 

Diarrheal diseases; both of adults and children, are much more 
frequent during hot than cold weather (and in hot than in cold 
climates), but it is probable that other factors, as the more ready 
putrefaction of food, aid in the production of these diseases besides 
the high temperature. 

Certain epidemic diseases are likewise more frequent in, or ex- 
clusively confined to, hot climates. These are cholera, yellow fever, 
and epidemic dysentery. Elephantiasis, malarial fevers, and certain 
skin diseases seem also to have some connection with a constantly 
high external temperature. The intimate relation between cause and 
effect is not clearly understood, although the belief is current that 
the origin and spread of such diseases depend upon the development 
of various parasitic organisms. 

Regarding the morbific effects of continued high temperatures, 
it is probable that an appropriate mode of life, proper diet, and suit- 
able clothing would avert many of the bad consequences. Neverthe- 



9 The Sun-stroke Epidemic of Cincinnati, 0., during the Summer of 1881, 
A. J. Miles, Public Health, vol. vii, pp. 293-304, 



INFLUENCE OF TEMPERATURE ON HEALTH. 13 

less, the fact remains that certain tropical or hot-weather diseases 
must be considered as primarily dependent upon high temperature, 
although the pathological effects may be due to an intermediate fac- 
tor. It is not improbable that micro-organisms will be found to ex- 
plain the occurrence of yellow fever, cholera infantum, and other dis- 
eases incident to hot weather. 

Extreme low temperature, as observed in the arctic regions, 
seems to produce a progressive deterioration of the blood (anemia), 
in consequence of which most natives of temperate regions who are 
compelled to remain in the far north longer than two winters suc- 
cumb to various hemic diseases, scurvy being the most prominent. 
It is not improbable, however, that the dietary furnished is respon- 
sible for a large share of the evil effects ascribed to cold. The ab- 
sence of sun-light for a considerable part of the winter season may 
also have much to do with the bad influences for which the low tem- 
perature is held responsible. 

Among the acute effects of great cold, frost-bite is the most fre- 
quent as well as the most serious. Loss of portions of the nose, or 
ears, or even of entire members are not infrequent results of frost-bite. 

In the arctic regions one of the most annoying affections which 
the traveler has to contend against is snow-blindness, a severe ophthal- 
mia produced by the glare of the snow. Neutral-tinted glass goggles 
should be worn as a preventive. 10 

Dr. Henry B. Baker 11 has placed upon record a large mass of 
observations which appear to indicate that most of the acute diseases 
of the respiratory organs are caused by a low temperature in con- 
junction with a low absolute humidity. Dr. Baker furnishes numer- 
ous diagrams, which seem to demonstrate that the curves for influ- 
enza, tonsillitis, croup, bronchitis, and pneumonia are in general out- 
lines all practically the same, and that they follow the curve for 
atmospheric temperature with surprising closeness, rising after the 
temperature falls and falling after the temperature rises. He claims 
that this sameness indicates that the controlling cause is one and the 
same for all of these diseases, and that, directly or indirectly, the 
atmospheric temperature is that cause. They are diseases of the air- 
passages, and may be supposed to be influenced or controlled by the 



10 See Prayer's Narrative of the Austrian Arctic Voyage of 1872-74, pp. 
250-3 and 317, for an account of the effects of cold on the organism, and on 
the best prophylactic measures to be adopted. The Report of the Surgeon- 
General of the U. S. Navy for 1880 also contains (pp. 350-8) a valuable memo- 
randum by Ex-Surgeon-General Philip S. Wales, on Arctic Hygiene. 

11 Trans. Ninth International Med. Congress, vol. v. 



14 TEXT-BOOK OF HYGIENE. 

atmosphere which passes through them. Although the curves are 
all similar, yet their differences still further support his view, because 
the order of succession of the several diseases is such as would be ex- 
pected if caused in the manner which he supposes. Thus, croup 
and influenza precede in time bronchitis and pneumonia; the curve 
for bronchitis shows that disease to respond quicker than does pneu- 
monia to the rise and fall of the temperature. He suggests that the 
explanation of the causation of these diseases has not been grasped 
before because one of the principal facts has not been apprehended, 
namely, the fact that cold air is always dry air; on the contrary, it 
has been generally stated that when these diseases occur the air is cold 
and damp. He explains that while the cold air is damp relatively it is 
always dry absolutely, and he thinks that its bad effects on the air- 
passages are mainly through its drying effects, which can best be 
appreciated by reflecting that each cubic foot of air inhaled at the 
temperature of zero, F. [ — 17.8° C], can contain only y 2 grain of 
vapor [1.33 grammes per cubic metre], while when exhaled it is 
nearly saturated at a temperature of about 98° F. [36.5° C], and 
therefore contains about 18 1 / 2 grains of vapor [about 43 grammes 
per cubic metre], about 18 grains of which have been abstracted from 
the air-passages. Thus cold air falling upon susceptible surfaces 
tends to produce an abnormal dryness which may be followed by irri- 
tation and suppuration. He claims that coryza is sometimes so 
caused. Under some conditions the nasal surfaces are not susceptible 
to drying, the fluids being supplied in increased quantity to meet the 
increased demand made by the inhalation of cold air. In that case 
an unusual evaporation of the fluid leaves behind an unusual quan- 
tity of non-volatile salts of the blood, such as sodium chloride, and 
an unusual irritation results; he thinks influenza is the name com- 
monly given to this condition. The effects which the inhalation of 
cold air has on the bronchial surfaces depend greatly upon how the 
upper air-passages have responded to the increased demand for fluids ; 
because, if they do not supply the moisture, it must be supplied by 
the bronchial surfaces, in which case bronchitis results. Finally, if 
the demands for moisture made by cold air are not met until the 
air-cells are reached pneumonia is produced. 

These claims are partly supported and partly opposed by an 
elaborate paper by Dr. J. W. Moore. 12 According to the statistics 
furnished by this writer, bronchitis and pneumonia show a remarkable 



12 The Seasonal Prevalence of Pneumonic Fever, Trans. Ninth Internat. 
Congress, vol. v. 



INFLUENCE OF TEMPERATURE ON HEALTH. 15 

contrast as to seasonable prev-alence. The statistics of London and 
Dublin agree very closely upon this point. Bronchitis falls to a very 
low ebb in the third or summer quarter of the year (July to Septem- 
ber, inclusive), when only 12 per cent, of the deaths annually caused 
by this disease take place in Dublin and only 11 per cent, in London. 
In the last or fourth quarter (October to December inclusive) the 
percentage of deaths from bronchitis rises to 27 in Dublin and 30 in 
London. The maximal mortality occurs in the first quarter (January 
to March, inclusive), when it is 38 per cent, in both London and 
Dublin. In the second or spring quarter (April to June, inclusive) 
the bronchitic deaths decline to 23 per cent, in Dublin and 21 per 
cent, in London. 

The mortality from pneumonic fever is differently distributed 
throughout the year. In the summer quarter more than 14 per cent, 
of the annual deaths referable to the disease are recorded in Dublin 
and more than 15 per cent, in London. In the first quarter the fig- 
ures are — London, 31 per cent. ; Dublin, 31 per cent. In the second 
quarter they are — London, 26 per cent. ; Dublin, 30 per cent. In the 
fourth quarter they are — London, 27 per cent.; Dublin, 24 per cent. 

It therefore appears that the prevalence and fatality of pneu- 
monic fever from season to season do not correspond with the seasonal 
prevalence and fatality of bronchitis. The latter disease increases and 
kills in direct relation to the setting in of cold weather; it subsides 
in prevalence and fatality with the advance of spring and the advent 
of summer. Pneumonic fever, on the other hand, increases less 
quickly in winter and remains more prevalent in spring than bron- 
chitis; its maximal incidence coincides with the dry, harsh winds 
and hot sunshine of spring, when the diurnal range of temperature 
also is extreme. 

Dr. Moore believes that acute bronchitis is produced directly 
by the influence of low temperature, while pneumonia requires an 
additional cause, which he supposes to be a specific micro-organism. 

Since Dr. Moore's observations the specific causes of pneumonia 
(the pneumococcus) and influenza (the influenza bacillus) have 
been firmly established, and it is quite likely that acute bronchitis, 
coryza, and other acute affections of the respiratory passages are 
caused by micro-organisms, the cold acting merely as a predispos- 
ing factor. 



16 TEXT-BOOK OF HYGIENE. 



HUMIDITY OF THE ATMOSPHERE AS CONNECTED WITH 
CHANGES IN HEALTH. 

The propagation of certain acute infectious diseases is believed 
to be due to a high relative humidity. There can be no longer any 
doubt that a very humid soil and air, especially if connected with a 
variable temperature, are almost constant factors in the predispo- 
sition to pulmonary phthisis. Recent experience in this country and 
abroad has shown that the high plateaus and mountains, far inland, 
where the soil is dry and the relative humidity of the air low, are the 
best resorts for consumptives, although excellent results in the treat- 
ment of tuberculosis have been achieved in sanatoriums located under 
the most adverse climatic conditions. 

Of the effects of excessively dry air on health little definite is 
known. It seems probable, however, that catarrhal affections of the 
respiratory mucous membrane are more frequent in a dry than in a 
humid climate. 13 



THE SANITARY RELATIONS OF AIR=CURRENTS. 

Primarily, winds or air-currents may be considered as favor- 
able to health. By the agitation of the air ventilation is secured, 
foul air removed from insanitary places, and diluted by admixture of 
purer air. But air-currents may also be regarded as either directly 
or indirectly unfavorably influencing health. 

Full credit is given by the public to cold winds and draughts 
in producing catarrhs and rheumatic pains. The progression of cer- 
tain infectious diseases, especially malaria, is believed with good 
reason to stand in a definite relation with the direction of the wind, 
which, if the latest theory of the causation of malaria be accepted, 
carries the infected mosquitoes. 

Certain local winds are known to have a deleterious effect upon 
living beings, especially when the latter are in bad health. Among 
these winds is the mistral, a cold, dry, parching northwest wind which 
blows along the Gulf of Lyons. It brings on rheumatism and mus- 
cular pains, and is said to excite pleurisy and pneumonia and to act 
unfavorably upon consumptives. 

The bora is a cold, dry wind coming down from the Alps and 
continuing across the Adriatic. 



13 See ante. 



SANITARY RELATIONS OF AIR-CURRENTS. 17 

The Texan northers are well known in the southwestern part of 
the United States. 'They are extremely dry, and are often accom- 
panied by a sudden fall of temperature. Changes of 28° C. (50° F.) 
within twelve hours are not infrequent in Western and Central Texas. 
Both man and beast suffer intensely from the cold, parching character 
of the wind. 

The sirocco of Northern Africa, Sicily, and Southern Italy has a 
world-wide notoriety for its depressing effect upon human energy. 
The harmattan is equally noted on the west coast of Africa. It is 
hot and dry, while in Southern Europe the sirocco is hot and moist. 

The simoon is a hot, scorching wind of India, and is said to be 
deadly in its effects upon vegetation and extremely deleterious to men 
and animals who are encountered by it. In Australia and South 
Africa hot winds are said to occur which completely destroy vege- 
table life in their track, and are often unwholesome in their effects 
upon animal life. 

The evil reputation of the Alpine fbhn is very well known, and 
neither native nor traveler is anxious to encounter it. It is warm 
and dry. 

With reference to the influence of electrical conditions of the 
atmosphere upon health, no observations have been made which jus- 
tify definite conclusions. 14 

Mr. Alexander Buchan and Dr. Arthur Mitchell have analyzed 
the influence of the weather and season upon the causation of disease, 
or, rather, upon the mortality from various diseases. 15 Taking the 
records of the city of New York from 1871 to 1877, it appears that 
the maximum number of deaths from small-pox occurred in May, 
the minimum in September. From measles there were two annual 
maxima and minima, the greater in July and September and the 
smaller in February and April. From scarlet fever the maximum 
was in April, the minimum in September. From typhoid fever the 
maximum was from August to November, the minimum almost 
equally distributed throughout the rest of the year; from diarrhea, 



14 Dr. S. Weir Mitchell has shown, from the record of the case of Captain 
Catlin, U. S. A. (American Journal Med. Sci., April, 1877, and N. Y. Med. Jour., 
August 25 and September 1, 1883), that attacks of neuralgia— in this case, at 
all events — accompanied the progress of storms across the continent. Also, 
that the periods of maximum pain occurred with a 'high but falling barometer 
and increasing absolute humidity. There seems also to be some relation in 
this case between the maximum pain and the maximum magnetic force as 
shown bv the declinometer. Dr. Mitchell's papers are among the most valu- 
able positive contribution to hygienic meteorology, and deserve careful study. 

15 Journal Scottish Meteorological Societv. 1875-78. (Abstract in Rich- 
ardson's Preventive Medicine, p. 533 et seq. Philadelphia, 1884.) 



18 



TEXT-BOOK OF HYGIENE. 




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SANITARY RELATIONS OF IMPURITIES IN AIR. 23 

the maximum in July and August, the minimum from December to 
March; from diphtheria, the maximum in December, the minimum 
in August; 10 from whooping-cough, maximum in September and 
February, minimum in November and June; for croup the curves 
agree pretty closely with the diphtheria curves; from phthisis, the 
maximum in March, minimum in June. 

The foregoing charts, reproduced by permission of the Massachu- 
setts State Board of Health from the report of that body for 1888, 
show an almost identical movement of the mortality from different 
diseases throughout the year. They exhibit the reported mortality for 
1888 and also for the six years from 1883 to 1888. 

From suicide, curiously, the greater number of deaths occurs in 
May, the smallest in February. This is contrary to the usual suppo- 
sition that gloomy weather predisposes to suicide. The six summer 
months — from April to September — show a much larger number of 
self-murders than the remaining half-year. In eleven years, ending 
1880, there were 1521 cases of self-destruction in New York. Of 
these 341 occurred during January, February, and March; 417 dur- 
ing April, May, and June; 412 during July, August, and September; 
and 351 during the last three months of the year. In Philadelphia, 
the results of examination of the statistics of suicide for ten years 
are almost exactly similar. Out of 636 cases of suicide, 78 occurred 
in May, 71 in August, 57 in December, 54 each in October, July, and 
April, 52 in June, 49 in November, 44 each in December and Feb- 
rurary, 43 in March, and 36 in January. 17 Dr. Lee is led to believe 
that "a low barometric pressure, accompanied by a high thermometric 
registry, with sudden fluctuations from a low to a high temperature, 
together with much moisture and prevailing southwest winds, might 
somewhat account for the frequency of self-murder in the spring 
and summer months/' 



THE SANITARY RELATIONS OF CHANGES IN COMPOSITION 
AND OF IMPURITIES IN THE AIR. 

The average proportion of carbon dioxide in the atmosphere is 
from 3 to 4 parts in 10,000. Pettenkofer 18 places the maximum limit 



16 See paper on the Relation of Weather to Mortality from Diphtheria in 
Baltimore, by Richard Henry Thomas, in Trans. Med. and Chir. Faculty of 
Maryland, 1883. 

17 Suicide in the City and County of Philadelphia during a Decade, 1872 
to 1881, inclusive, by John G. Lee, Trans. Am. Med. Asso., vol. xxxiii, p. 425. 

13 Quoted in Buck's Hygiene and Public Health, vol. i, p. 615. 



24 TEXT-BOOK OF HYGIENE. 

of carbon dioxide allowable in the air of dwellings at 7 parts in 
10,000. It is probable that this limit is very frequently exceeded 
without serious consequences to health, if the air is not at the same 
time polluted by organic impurities, the products of respiration. 
Professor William Ripley Nichols found the air in a school-room in 
Boston to contain eight times the normal proportion of carbon di- 
oxide, while Pettenkofer found, also in a school-room, after the same 
had been occupied two hours, eighteen times the normal proportion, 
or 72 parts in 10,000. 19 While such an excess of this poisonous gas 
must unquestionably have an unfavorable influence upon health, it 
is probab'e that the most serious effects are due to the coincident 
diminution of oxygen and the pollution of the air by the products of 
respiration which necessarily take place during respiration. Carbon 
dioxide alone may be present in the air to a much greater extent than 
above mentioned without causing any appreciable inconvenience. In 
the air of soda-water manufactories there is frequently as large a 
proportion as 2 per cent, of this gas present without producing any 
ill effects upon those breathing such an atmosphere. 

The amount of carbon dioxide in the atmosphere is greatest at 
night. It is also greater very near the ground than at a distance of 
several feet above it. As carbon dioxide is absorbed by the leaves of 
plants during the day-time, but given off at night, the difference may 
partly be thus accounted for. According to Fodor, 20 the source of a 
large proportion of the carbon dioxide in the air is the decomposition 
going on in the soil. This accounts for the larger percentage of car- 
bon dioxide near the ground. This would also explain the variation 
of the proportion of carbon dioxide in the air under different meteoro- 
logical conditions. For example, it is found that during rainy 
weather the carbon dioxide in the air is diminished. This is accounted 
for partly by the absorption of the carbon dioxide by the saturated 
ground, while at the same time the porosity of the soil is diminished 
and the escape of the ground-air prevented. 

Mr. E. Angus Smith made a number of experiments upon him- 
self to determine the effects of an atmosphere gradually becoming 
charged with the products of respiration and perspiration. His ex- 
periments were conducted in a leaden chamber holding 5 cubic metres 
of air. This air was not changed during the experiment. After re- 
maining for an hour in this chamber, an unpleasant odor of organic 



19 See table in Buck's Hygiene and Public Health, vol. i, p. 612. 
20 Hygionische Untersuchungen ueber Luft, Boden und Wasser, Braum- 
schweig. 1882 2te Abth. 



SANITARY RELATIONS OF IMPURITIES IN AIR. 25 

matter was perceptible on moving about. The air, when agitated, felt 
soft, owing, doubtless, to the excess of moisture contained in it. The 
air soon became very foul, and, although not producing any discom- 
fort, the experimenter states that escape from it produced a feeling 
of extreme pleasure, like "that which one has when walking home 
on a fine evening after leaving a room which has been crowded." 21 

Hammond 22 confined a mouse in a large jar in which were sus- 
pended several large sponges saturated with baryta water, to remove 
the carbon dioxide as rapidly as formed. Fresh air was supplied as 
fast as required. The aqueous vapor exhaled was absorbed by cal- 
cium chloride. The mouse died in forty-five minutes, evidently from 
the effect of the organic matter in the air of the jar. The presence 
of this organic matter was demonstrated by passing the air through 
a solution of potassium permanganate. 

The horrible story of the "black hole" of Calcutta is familiar 
to every one. Of 146 prisoners confined in a dark cell at night, 23 
were found alive in the morning. Among the survivors a fatal form 
of typhus fever broke out, which carried off nearly all of them. After 
the battle of Austerlitz 300 prisoners were crowded in a prison; 260 
died in a short time from inhaling the poisoned air. Numerous other 
similar examples of the effects of polluted air are recorded. 

Usually the effects of foul air are not so sudden and striking. 
In most instances, especially where the pollution has not reached a 
high degree, there simply results a general deficiency of nutrition, 
which manifests itself in anemia, loss of vigor of body and mind, and 
a gradual diminution of resistance to disease. 

It seems to be beyond question that persons who are constantly 
compelled to inhale impure air, especially if combined with an im- 
proper position of the body or lack of sufficient or appropriate food, 
furnish a very large percentage of chronic pulmonary affections. 
Phthisical patients, in the overwhelming majority of cases, are 
drawn from the classes whose occupations keep them confined in close 
rooms. Want of exercise and of good food doubtless aid in the de- 
velopment of the lung disease. Formerly, when less attention was 
paid to the proper construction and ventilation of barracks and 
prisons, the mortality from phthisis among soldiers and criminals was 
much greater than it is now. In animals kept closely confined the 
same disease claims a large share in the mortality. 

21 Air and Rain, p. 138. 

22 A Treatise on Hygiene, with Special Reference to the Military Service, 
by William A. Hammond, M.D., Surgeon-General U. S. Army, p. 170, Phila- 
delphia, 1863. 



TEXT-BOOK OF HYGIENE. 

Near the end of the last century over one-third of the infants 
born in the old Dublin Lying-in Hospital died of epidemic diseases. 
After the adoption of an improved system of ventilation the mor- 
tality fell to about one-tenth" of what it had previously been. To 
illustrate the effect of similar conditions upon the health of domestic 
animals, the following instance is cited: Upward of thirty years ago 
a severe epidemic of influenza in horses appeared in Boston. At the 
instigation of Dr. H. I. Bowditch, every stable in the city was in- 
spected, and classified as "excellent/ 7 "imperfect," or "wholly unfit," 
in respect to warmth, dryness, light, ventilation, and cleanliness. It 
was found that in the first class fewer horses were attacked and the 
disease was milder, while in the third class every horse was attacked 
and the more severe and fatal cases occurred. 

Carbon monoxide is a very dangerous impurity often present in 
the air of living-rooms. Being an ingredient of illuminating gas, as 
well as the so-caP.ed coal-gas which so frequently escapes from stoves 
and furnaces, its dangerous character becomes apparent. Many per- 
sons die every year in this country from the inhalation of illuminating 
gas. People unacquainted with the mechanism of gas-fixtures fre- 
quently blow out the light instead of cutting off the supply of gas by 
turning the stop-cock. It is also a prevailing custom to keep the 
light burning "low" during the night. Any considerable variation 
of pressure in the pipes, or sudden draught, may put out the light 
and permit the gas to escape into the room, with fatal effect. Leaks 
in pipes or fixtures may have the same results. Chronic poisoning 
with minute quantities of illuminating gas is very common, especially 
in large cities, and many cases of obscure anemia and ill-health are 
due to this cause. 

Coal-, coke-, or charcoal- fires may produce serious or fatal 
poisoning if the gas, which contains a large proportion of carbon 
monoxide, is permitted to escape into the room. 23 In certain parts of 
Europe, notably in France, the inhalation of the fumes of a charcoal 
fire is a favorite method of committing suicide. 

The gas which sometimes escapes from the stove when coal is 
burning has the following composition : — 

Carbon dioxide 6.75 per cent. 

Carbon monoxide 1.34 " 

Oxygen 13.19 

Nitrogen 78.72 

23 See paper bv Dr. John Graham in Transactions of Philadelphia College 
of Physicians for 1885. 



SEWER-AIR. 27 

Sulphuretted and carburetted hydrogen are not infrequently 
present in the air, especially about cess-pools and in mines and 
certain manufacturing establishments. Sulphuretted hydrogen is 
generally considered to be a violent poison, but there is no evidence 
that it is so unless oxygen is excluded. 

Carburetted hydrogen is the so-called "fire-damp" of mines, 
which is so often the cause of fatal explosions. Its inhalation does 
not seem to be especially noxious. It will be more fully referred to 
in a succeeding chapter. 

Variations in the proportion of ammonia present in the air are 
frequent. Its presence is an indication of organic decomposition in 
the vicinity, but nothing is known of the influence of the gas itself 
upon health, in the proportion in which it is ever found in the atmos- 
phere. 

SEWER=AIR. 

Sewer-air, or sewer-gas, as it is often improperly called, is a vari- 
able mixture of a number of gases, vapors, atmospheric air, and solid 
particles, and is derived from the decomposition of the animal and 
vegetable contents of sewers. A number of analyses by different 
chemists have shown that the composition of sewer-air is extremely 
variable. The most important components, in addition to the con- 
stituents of atmospheric air, are: Carbon dioxide, ammonia, sul- 
phuretted hydrogen, and a number of volatile organic compounds, 
which give to sewage its peculiar odor, but which are present in such 
small quantity as to prevent accurate determination by chemical 
means. Sewer-air may also contain particulate bodies, bacteria, and 
other microscopic organisms, which may be the active causes of in- 
fectious diseases. Some recent researches by Carnelly and Haldane 
have shown that sewer-air usually contains a less number of micro- 
organisms than the external air of cities. The proportion of carbon 
dioxide found was also much less than was expected. When the con- 
tents of sewers remain in these receptacles or conduits long enough 
to undergo decomposition, sewer-air is always present. 

The continual breathing of air polluted by emanations from sew- 
ers often produces more or less serious derangements of health. 
Diarrhea and other intestinal affections and mild cases of continued 
fever have been frequently noted in connection with defective sewer- 
age, and the escape of sewer-air into inhabited rooms. 

The effluvia from cemeteries, knackeries, and other places where 
the bodies of animals are undergoing decomposition, are popularly 



28 TEXT-BOOK OF HYGIENE. 

regarded as deleterious in their effects upon health. The evidence in 
favor of this view is, however, very indefinite. 

Professor Tvmlall has shown- 4 that even the apparently clearest 
air is, when in motion, constantly filled with innumerable particles of 
dust, which are the carriers of various micro-organisms. The pres- 
ence of these particles can be easily demonstrated by means of the 
electric light. Every one has observed these minute particles in a 
bright ray of sun-light. Under ordinary conditions these particles 
of dust would, of course, give rise to no trouble, but if intermingled 
with these dust-specks there were disease germs, then manifestly the 
inhalation of such "dust" would be dangerous. 25 

The quantity of dust found in the air of cities is mueh greater 
than in the country. Tissandier found that in Paris the percentage 
of dust was eight to twelve times greater than in the open country. 
One-fourth to nearly one-half of this atmospheric dust is organic, 
either animal or vegetable. Very recent observations have shown that 
in Paris the air contains nine or ten times as many bacteria in a given 
volume as the air at the observatory of Montsouris, just without the 
city. The relative proportions of organic and inorganic particles vary 
as 25 to 75 in Paris, 45 to 55 in Dublin, and 25 to 75 in the open 
country. The organic particles are either particles of dead organic 
matter, or minute organisms. The proportion of the latter varies in 
different seasons, being the least in winter and spring, and greatest 
in summer and autumn. These organisms are not necessarily patho- 
genic, but the conditions which favor the proliferation of non-patho- 
genic bacteria are likely to promote the development of disease-pro- 
ducing ones likewise. 

Among the pathogenic micro-organisms which may be found in 
the atmosphere are spores of achorion Schoenleinii, streptococci, 
staphyloccoci, the bacilli of tuberculosis, cholera, and typhoid fever, 
and other micro-organisms which produce disease. 

It is advisable in all cases to exhaust the stagnant air in old 
wells and privy-vaults before permitting any one to descend. Per- 
haps the readiest method of^ exhausting the vitiated air in such places 
would be to lower heated stones, masses of hot iron or pails of hot 
water, to near the bottom, which produce a rarefaction of the air and 
cause it to ascend. Its place will then be occupied by purer air from 
without. The rarefaction produced by the explosion of gun-powder 



24 Essays on Floating Matter of the Air. New York, 1882. 

25 See Chapter IX, on Industrial Hygiene, for effects of inhalation of dust 
in various industries. 



THE EXAMINATION OF AIR. 29 

has also been made use of with success; but this has some objections, 
because the combustion of powder itself produces gases which are 
noxious if breathed in large quantity. An animal, such as a cat or 
dog, should be first lowered into the suspected well for fifteen or 
twenty minutes, in order to determine whether the air at the bottom 
is capable of sustaining life, before permitting the workmen to 
descend. Similar precautions should be used in old, long-unused 
mines to prevent fatal effects from the so-called "choke-damp," which 
is largely composed of carbon dioxide. 



THE EXAMINATION OF AIR. 

Occasions often arise wherein physicians or others desire infor- 
mation concerning the atmosphere of apartments or confined spaces. 
They have neither time, apparatus, nor, possibly, the skill necessary 
to obtain the accurate results of the expert chemist or bacteriologist; 
nor do they require that the information which they seek should be 
so extremely exact. 

In the preparation of this chapter, therefore, such methods of 
procedure will be detailed as will serve to determine, with reason- 
able accuracy and with moderate requirements of time, expense, or 
technical skill, the hygienic condition of the substances examined. 
The apparatus and reagents will also be found, for the most part, to 
be cheap and easily obtainable, and they may often be improvised 
or prepared from material already at hand. Moreover, a little thought 
will show how a number of these methods may be developed along 
the line of greater accuracy, should this be desired, and the principles 
involved will indicate how similar examinations may be made of 
other phases of the respective subjects not herein discussed. 

The substances in the atmosphere whose proportions or charac- 
teristics it may be important to determine are: the aqueous vapor; 
ozone; suspended particles, both organic and inorganic; living 
micro-organisms; volatile organic matters, and the various gases 
given off as products of respiration, combustion, etc., or in the course 
of certain manufacturing processes. 

The proportion of aqueous vapor is to be determined by some 
form of hygrometer, such as Lambrecht's polymeter, or from the 
readings of wet- and dry- bulb thermometers, which readings, when 
applied to Glaisher's tables, furnish a means of determining the 
relative and the absolute humidity, the dew-point, the weight of water 
to a given volume of air, etc. 



30 TEXT-BOOK OF HYGIENE. 

The presence of ozone in the atmosphere may be demonstrated 
by exposing to the air strips of white blotting- or filter- paper which 
have been saturated with a solution of potassium iodide and starch and 
dried. The ozone, decomposing the potash salt, liberates the iodine 
and colors the starch blue. During the test the paper should not be 
exposed to dust, rain, wind, or the direct rays of the sun. Another 
test (Houzeau's), perhaps even more delicate, is to dampen a strip 
of faintly-red litmus-paper with a solution of the iodide and dry. 
The action of ozone upon this is to liberate the alkaline potash and 
change the litmus to blue. As ammonia is the only other gas likely 
to produce the same coloration, if another strip of the litmus-paper, 
not moistened with the salt, be exposed at the same time, whatever 
difference in shade there may be in the papers is due to the ozone. 
An idea of the quantity of ozone present may also be gained by com- 
paring the shade of blue given by either test with that produced in 
similar strips of the starch- or litmus- paper, respectively, which 
have been exposed to certain definite amounts of ozone, a series of 
such papers forming a standard of comparison. 

It may be suggested, for still another test, that a definite quantity 
of the air to be examined be drawn through a faintly-acid solution 
of the potassium iodide, phenolphthaleine being used as an indicator. 
As soon as sufficient alkali is liberated to neutralize the acidity, the 
pink color of the phenolphthaleine will be developed and will deepen 
as the proportion of free alkali increases. Here, also, a control-test 
to eliminate the influence of ammonia should be made by drawing a 
similar quantity of air through the same amount of the solution 
minus the potassium iodide. As before, the difference in color- 
shading will be proportional to the amount of ozone in the air. 

Numerous methods have been suggested for the collection of the 
solid impurities of the atmosphere, varying according to the kind or 
extent of examination to which they are to be subjected. If they are 
simply to be studied microscopically, glass slides coated with glycerin 
and exposed to the air will be sufficiently covered after several hours, 
or they may be collected more rapidly by aspirating large quantities 
of the air against such slides or through tubes coated interiorly with 
glycerin, as by means of Pouch et's aeroscope or by the apparatus de- 
vised by Dr. S. G. Dixon. This latter is especially advantageous 
where it is desired to collect samples of dust in the air of a number 
of localities within a short time, and consists essentially of a double 
cylinder of metal, within which is a rack carrying a number of 
glycerin- or gelatin- smeared cover-glasses. By an ingenious arrange- 



THE EXAMINATION OF AIR. 31 

ment the air can be aspirated by means of a hand-bulb over each of 
these glasses in turn, the dust particles being deposited on the sticky 
surface, and thus the samples may be taken from as many localities as 
there are cover-glasses. Moreover, the specimens may be mounted 
and examined as they are, may be stained, or, if the glasses be coated 
with gelatin and the whole apparatus be sterilized before the collec- 
tion, colonies of the bacteria, etc., in the dust may be allowed to de- 
velop on the glasses and be studied in loco under the microscope. 

Another satisfactory method of collecting suspended particles is to 
draw a considerable volume of air very slowly through a small quantity 
of distilled water contained in one or two wash-bottles. The solid 
particles may then be allowed to settle, and subsequently be removed 
for microscopical examination by means of a pipette, or the whole 
may be filtered and the weight of the dust in the aspirated air thus 
obtained. It might also be well, in the latter case, to evaporate the 
filtrate to dryness and to determine what proportion of the residue is 
organic matter, and what are its nature and effects when administered 
to animals. Lastly, the air may be slowly drawn through a small 
tube packed with pure sugar, the sugar afterward being dissolved in 
distilled water, whence the solid particles taken from the air may be 
removed by means of a pipette or by filtration. 

The physical nature of the particles of dust thus collected is to 
be determined by means of the microscope, it being presumed that the 
examiner is sufficiently familiar with the instrument to recognize at 
sight the more common materials that are apt to pervade the air of 
occupied apartments, such as bits of cotton, wool, hair, epithelium, 
etc. Charring on ignition will indicate that the residue is, at least, 
partly organic, and the odor of burnt feathers that it is nitrogenous 
and probably of animal origin. Suitable chemical tests will also de- 
termine the presence or absence of suspected substances. Thus, an 
examination of the dust by Marsh's or Keinsch's test may reveal the 
presence of arsenic, and lead to an investigation as to its source. 

However, since Cornet and others have demonstrated that the 
micro-organisms in the air are, in general, closely adherent to the 
dust-particles, a bacteriological examination of the latter will, except 
in special cases, be of more importance than a physical or chemical 
one. 

To make a qualitative bacteriological examination it is only 
necessary to coat the glass plates or tubes, already described, with 
nutrient gelatin instead of glycerin, and to sterilize them before use. 
They are then exposed to the air as before, covered, and set aside in 



32 



TEXT-BOOK OF HYGIENE. 




Fig. 1. — Organic Matters Frequently Present in Dust. S, Fibers 
of Silk; C, of Cotton; L, of Linen; W, of Wool. F, Feather. St, 
Starch-granules. Cr, Cork. 0, Torulse. M, Mycelia, or Threads, of 
Mildew. Mc, Micrococci. B, Bacteria. Lt, Leptothricial Filaments. 
(After Heitzmann.) X 500. 



a place of proper temperature to allow the colonies to develop from 
the various micro-organisms which have adhered to the sticky sur- 
faces; or Dr. Dixon's apparatus, with gelatin-coated glasses, may be 
used in the manner described. 



THE EXAMINATION OF AIR. 33 

A quantitative bacteriological examination is almost as readily 
made by drawing a given quantity of air through a sugar-filter, as 
stated. The tube should not be too large in diameter nor in length, 
should be filled with pure granulated sugar and the ends temporarily 
plugged with cotton, and should, of course, be sterilized before mak- 
ing the test. After the air has been drawn through it the sugar is 
carefully emptied into tubes or flasks of nutrient gelatin, which have 
been heated just enough to melt the gelatin, but not sufficiently high 
to kill the bacteria, etc., which have been caught in the sugar. The 
latter rapidly dissolves and leaves the micro-organisms free to de- 
velop in the gelatin, which may be poured out before cooling upon 
sterilized glass plates or into shallow (Petri) dishes. So-called col- 
onies rapidly develop from the individual bacteria, and the total num- 
ber of these colonies may be assumed to represent the number of 
micro-organisms in the quantity of air aspirated through the filter. 
Moreover, from these colonies pure cultures may be made, and the 
nature, etc., of the respective microbes determined. To determine the 
quantity of organic matter in the air the most feasible method is to 
slowly draw a certain volume of air through a given quantity of twice- 
distilled ammonia-free water, which retains not only all the volatile 
and suspended organic matters, but also the gases originating there- 
from. The water is then to be tested by the Wanklyn process for 
"free" and "albuminoid" ammonia, and, if desired, by the Tidy- 
Forchammer process for oxidizable organic matter, though it should 
be noted that in the latter process other gases present in the air, such 
as sulphuretted hydrogen, may help to decolorize the permanganate 
solution, and must therefore be excluded or estimated separately. 

However, as these processes are, perhaps, too complex for the 
purpose of this chapter, and as it has been shown by de Chaumont and 
others that the organic matter with which we are usually most con- 
cerned — namely, that given off from human bodies as a product of 
respiration and like processes — is produced in quantities proportional 
to the amount of carbon dioxide eliminated in the same processes, it 
generally suffices for our purpose to determine the proportion of this 
gas in the atmosphere, especially as this determination is much more 
readily made than the foregoing one. 

The methods devised by Wolpert and Angus Smith for rapidly 
estimating the percentage of carbon dioxide have been materially 
simplified by Professor Boom. 

Professor Boom has suggested that, instead of the special and 
somewhat expensive apparatus of Professor Wolpert, a mark be made 



34 



TEXT-BOOK OF HYGIENE. 



on any test-tube, — say, one inch from the bottom. Fix the bulb of 
any atomizer to a small glass tube — a capillary one, if possible — suffi- 
ciently long to reach the bottom of the test-tube, and in such a man- 
ner that a definite volume of air is driven from the atomizer-bulb 
through the tube at each compression of the former. In using, fill 
the test-tube exactly to the mark with a clear, saturated solution of 
lime-water, and find how many compressions are needed in the out- 
door air — forcing the air through the lime-water each time and taking 
care not to draw any fluid up into the bulb — to make the fluid just 
turbid enough to obscure a pencil-mark or print on white paper placed 

beneath the test-tube and viewed from 

# above. Clean the test-tube thoroughly, 

and repeat the process in the apartment 
of which the air is to be examined. As- 
suming that the out-door air contains the 
normal proportion of carbon dioxide, — 
viz., 0.04 per cent., — the percentage in the 
air of the room is determined as follows: 
The number of compressions of the 
bulb in the out-door air : the number of 
compressions in the room : : x : 0.04 
per cent., x representing the percentage of 
carbon dioxide in the air of the room. 

As a modification of the Angus Smith 
method, the author would suggest the fol- 
lowing as being, perhaps, more accurate, 
and as certainly not requiring so much 
apparatus, etc. : — 

To a wide-mouthed bottle, holding 
about a quart or litre, fit a doubly-per- 
forated rubber stopper, one perforation being just large enough to 
receive the tip of a 1 c. c. pipette, the other carrying a small test- 
tube, its mouth opening into the jar and close to the inner surface 
of the stopper. Fill the bottle and test-tube with the air of the 
room by filling them with water and emptying; fit in the stopper, 
and introduce, by means of a 1 c. c. pipette, a cubic centimetre at a 
time of a standardized alkaline solution, slightly colored with a few 
drops of a neutral alcoholic solution of phenolphthaleine. Close the 
pipette perforation in the stopper with a bit of glass rod and shake 
the bottle well each time after adding the alkaline solution. Con- 
tinue in this way until the color is no longer discharged by the acid 



E->iA 






Fig. 2. — Air-tester. 



THE EXAMINATION OF AIR. 35 

carbon dioxide of the air. By having the test-tube fitted in the stop- 
per as above and inverting the bottle, the same thickness of fluid is 
observed each time, and there is more accuracy than if the bottle is 
used without the test-tube. In either case the fluid should be ex- 
amined by looking through it against a white light or surface. 

Now, since the quantity of the alkaline fluid used indicates a cor- 
respondingly definite amount of carbon dioxide, — 

the number of c. c. of solution used X the volume of CO* each c, c. represents X 100 
the capacity of the bottle and test-tube in c. c. — the number of c. c. of solution used 

= the percentage of carbon dioxide in the air examined. 

A suitable alkaline solution may be prepared by dissolving ex- 
actly 4.766 grammes (73.549 grains) of pure anhydrous sodium car- 
bonate in 1 litre (35.238 fluidounces) of distilled water. Each cubic 
centimetre of this solution is equivalent to a like volume of carbon 
dioxide. To 10 cubic centimetres of this solution add a few drops of 
a neutral alcoholic solution of phenolphthaleine and dilute with dis- 
tilled water to 100 c. c. Each cubic centimetre of the dilute solution 
will now be neutralized by 0.1 of carbon dioxide, and, if used as sug- 
gested, should give close results. The phenolphthaleine is used as 
an indicator, as it loses its color as soon as the alkalinity of the soda 
solution is destroyed by the carbonic acid. Example : If 11 c. c. of 
the foregoing dilute solution be used, and the capacity of the bottle 
and test-tube is 1153 c. c, then 

n x o.i x 100 no 

= = 0.0963,— 

1153 — 11 1142 

the percentage of carbon dioxide in the air of the apartment. The 
firs't (stock) solution must be kept in well-filled and tightly-stoppered 
bottles, and the dilute solution made up as needed. 

Pettenkofer's method for determining the percentage of carbon 
dioxide in the air, which is usually considered the best, is as follows : 
Into a large, clean bottle or jar, filled with the air of the room as on 
page 34, introduce 50 c.c. of a clear, saturated solution of lime (cal- 
cium hydrate), stopper the bottle, and shake it well, so that the air 
may be well washed by the lime-water. This shaking should be re- 
peated at intervals for several hours, from eight to ten hours being 
required for the lime-water to absorb all the carbon dioxide in the 
air in the jar. (However, if baryta — barium hydrate — water be used 
instead of the lime-water, the absorption will be. completed in an 
hour.) 



36 TEXT-BOOK OF HYGIENE. 

The strength of the lime- (or baryta-) water being unknown and 
variable, it is determined by means of an oxalic-acid solution of such 
strength that 1 c. c. corresponds in acidity to 0.5 c. c. of carbon 
dioxide. Such a solution is made by dissolving exactly 2.84 grammes 
(43.827 grains) of pure crystallized oxalic acid in 1 litre of freshly- 
distilled water. This acid solution is run into 25 c. c. of the lime- 
water in a beaker from a graduated burette, or pipette, until the al- 
kalinity of the lime is just neutralized, the neutral point being indi- 
cated either by means of a few drops of a neutral phenolphthaleine 
solution in the beaker or by turmeric paper, the latter being 
colored brown, and the phenolphthaleine retaining its color as long 
as the solution is alkaline. When the lime is exactly neutralized 
the amount of the acid solution used from the burette is noted. 
Then 25 c. c. of the lime-water from the testing-bottle i& meas- 
ured into a beaker, and its acidity determined in the same man- 
ner by means of the oxalic-acid solution. Now, since part of the 
lime in the solution in the testing-bottle has already been neu- 
tralized by the carbonic acid of the air therein, it will require less 
of the acid solution to neutralize the lime-water from the bottle than 
it did to neutralize the same quantity from the stock solution, and 
the difference will indicate the exact amount of carbon dioxide in the 
air in the testing-bottle. For, though each cubic centimetre of acid 
solution is equivalent to only one-half cubic centimetre of carbon di- 
oxide, the loss of alkalinity of only half the lime-water in the bottle 
has been determined, and the total logs would be expressed by twice 
the difference found. The number of cubic centimetres of carbon 
dioxide in the air in the bottle having been thus determined, and the 
capacity of the bottle found by measuring the quantity of water it 
will hold, the percentage of carbon dioxide in the air is readily de- 
termined. For example: 25 c. c. of stock lime-water requires 30 
c. c. acid solution, and 25 c. c. of lime-water from testing-bottle re- 
quires 27 c. c. acid solution; therefore, 30 — 27 = 3 c. c, — the 
amount of carbonic acid in the bottle, which contains, say, 2250 c. c. 
Then— 

3 X 100 300 

— = 0.12,- 

2550 — 50 2500 

the percentage of carbon dioxide in the room at the current temper- 
ature and pressure. Tt should be noted that the accuracy of all these 
tests is somewhat vitiated by other acid gases, if present in the air, 
and due allowance should be made wherever they are suspected. 



THE EXAMINATION OF AIR. 37 

As has been intimated, baryta-water may be used in place of the 
lime-water, being more rapid in action, but considerably more ex- 
pensive, than the latter. The solution should be made of the strength 
of about 7 grammes of crystallized barium hydrate to the litre of 
distilled water; it must not be forgotten, also, that it is poisonous 
when taken internally. A good indicator, in addition to the phenol- 
phthaleine and turmeric, is methyl-orange, which is yellow in alka- 
line and of a reddish tint in acid solutions. 

The quantity of ammonia in the atmosphere may be determined 
by drawing a certain volume of air through ammonia-free water and 
then "Nesslerizing" the latter, as in the Wanklyn process of water 
analysis. So, also, the presence and percentage of other gases, such 
as nitric, hydrochloric, sulphurous, and sulphuric acid, sulphuretted 
hydrogen, ammonium sulphide, etc., are obtained by drawing the air 
through distilled water and subsequently making the proper chemical 
tests. For instance, the sulphur gas will darken a solution of lead 
acetate and ammonium sulphide will change the blue color of nitro- 
prusside of sodium to violet; consequently, the air may be drawn 
through standard solutions of these reagents and the resulting col- 
oration compared with that produced by known quantities of the re- 
spective gases. 

The presence of carbon monoxide is shown by the darkening of 
a solution of palladium chloride or sodio-chloride, but a more deli- 
cate test is that of Yogel by means of the spectroscope, which will 
show the presence of as little as 0.03 per cent, of the gas. In this test 
a drop of fresh blood is mixed with a little pure water and the mix- 
ture well shaken with a sample of the air in a jar. Then a few 
drops of ammonium sulphide are added and the fluid examined spec- 
troscopically. If carbon monoxide is present the spectrum of oxy- 
hemoglobin will be seen, it not having been reduced by the ammo- 
nium sulphide; but if the carbon monoxide is not present, we slrall 
have the spectrum of reduced hemoglobin. 

As even very small quantities of carbon monoxide in the air are 
harmful, it will not often be necessary to make a quantitative test for 
it ; but should this be desired, it can be done by passing a given volume 
of air several times through a solution of subchloride of copper, 
which absorbs the carbon gas, and then determining the loss of vol- 
ume the air has suffered by means of the eudiometer. 



3S TEXT-BOOK OF HYGIENE. 



PRINCIPLES OF VENTILATION. 

During ordinal*}' respiration an adult human being adds 900 
grammes = 455,500 cubic centimetres (14 cubic feet) of carbon di- 
oxide to, and abstracts 744 grammes = 516,500 cubic centimetres 
(16 cubic feet) of oxygen from the atmosphere in twenty-four hours. 
Hence, if the individual were confined in an apartment where the 
inclosed air could not be intermingled by diffusion with the atmos- 
phere without, the proportion of carbon dioxide would soon become so 
great that the processes of life could not be sustained, and the in- 
dividual would die. This result would be reached even sooner than 
the point here mentioned, for the organic matter exhaled from the 
lungs and the surface of the body would increase the poisonous con- 
dition of the air even more than the carbon dioxide given off. It is 
easily seen, therefore, how important the study of the principles and 
practice of ventilation becomes in r-jgiene. In this chapter only the 
principles underlying this subject can be definitely stated. Practical 
details will be more fully given in the chapters devoted to dwellings, 
schools, hospitals, etc. 

It is generally accepted among sanitarians that the presence of 
.07 per cent (7 parts in 10,000) of carbon dioxide in the air indi- 
cates the greatest amount of organic impurity (from respiration or 
combustion) consistent with the preservation of health. As each in- 
dividual gives off from his lungs, in the process of respiration, 316 
cubic centimetres of carbon dioxide per minute, the diffusion in the 
air surrounding him must be sufficiently rapid to keep the air to be 
breathed at the standard of .07 per cent, above mentioned. 

Adopting this as the standard of maximum impurity allowable, 
90 cubic metres of fresh air per hour will be needed for each indi- 
vidual to keep him supplied with pure air. This is for a person in 
a state of health; in cases of disease a more rapid change of air will 
be necessary to keep that surrounding the patient in a state of purity. 

Ventilation is defined by Worcester as "the replacement of nox- 
ious or impure air in an apartment, mine, or inclosed space by pure, 
fresh air from without/' By Dr. Parkes the term is restricted to 
"the removal or dilution, by a supply of pure air, of the pulmonary 
and cutaneous exhalations of men and the products of combustion of 
lights in ordinary dwellings, to which must be added, in hospitals, 
the additional effluvia which proceed from the persons and discharges 
of the sick. All other causes of impurity of air ought to be ex- 



PRINCIPLES OF VENTILATION. 39 

eluded by cleanliness, proper removal of so! id and liquid excreta, and 
attention to the conditions surrounding dwellings." 20 

A proper system of ventilation must take into consideration the 
cubic space of the apartment or building to be ventilated, the num- 
ber of persons ordinarily inhabiting this space, whether constantly or 
only temporarily occupied, and certain other collateral elements, such 
as the character of the building to be ventilated, its exposure, neces- 
sity for artificial heating, etc. 

The amount of cubic space that must be allowed to each indi- 
vidual is determined by the rapidity with which fresh air must be 
supplied in order to keep that surrounding the individual at the 
standard of less than .07 per cent, of carbon dioxide. For example, 
in a space of 3 cubic metres, the air must be changed thirty times in 
an hour in order to prevent the carbon dioxide exceeding the above 
proportion; that is to say, to allow 90 cubic metres of air to pass 
through that space in the time mentioned. This would create an 
uncomfortable, if not injurious, draught. If the space contained 30 
cubic metres, the air would need renewal only three times an hour. 

A space of 15 cubic metres could be kept supplied with pure air 
without perceptible movement if all the mechanical arrangements for 
changing the air were perfect; but such perfection is rarely attain- 
able, and hence there would be either draughts or insufficient venti- 
lation in such a small "initial air-space," as it is termed. The initial 
air-space should, therefore, be not less than 30, or, better, 40 cubic 
metres. The air of this space could be changed sufficiently often to 
keep it at its standard of purity without creating unnecessary 
draught. For sick persons this should be doubled. In hospitals, 
therefore, the cubic air-space allowed to each bed should be not less 
than 60 to 80 cubic metres. 

As stated, the purposes for which the building or apartment to 
be ventilated is employed require differences in the cubic space and 
in the volume of fresh air supplied. In Table III (page 40) Morin 
gives the cubic space for various purposes. 

These figures are not excessive from a sanitary standpoint, 
although few buildings meet the requirements here set down. 

The source of the air supplied must, of course, be capable of 
yielding pure air. It should not be drawn from damp cellars or base- 
ments, or from the immediate vicinity of sewers or drains. Air taken 



Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 157. 



40 TEXT-BOOK OF HYGIENE. 



Table III 

Hospital wards for ordinary cases 60-70 cubic metres. 

Hospital wards for surgical and obstetrical cases. . 100 

Hospital wards for contagious diseases 150 

Frisons 50 

* ^ ordinary occupations GO 

A I unhealthy occupations 100 

Barracks \ during tne da ^ 30 

I during the night 40-50 

Theatres 40-50 

Assembly rooms for long receptions GO 

Assembly rooms for brief receptions 30 

Primary schools 12-15 

Higher schools 25-30 

Stables 180-200 

from such places is little better for respiration than that which it 
replaces in the apartments to be ventilated. 

Ventilation may be accomplished either with or without arti- 
ficial aids. In buildings or rooms, used as habitations, natural ven- 
tilation (with, perhaps, the simplest mechanical aids) is made use 
of almost entirely. In large buildings, such as churches, theatres, 
schools, or in ships and mines, one of the artificial systems must be 
adopted if efficient ventilation is desired. 

Xatural ventilation takes place by diffusion, by perflation, and 
in consequence of inequality of atmospheric pressure. By diffusion 
is meant the slow and equable entrance of air from without and exit 
from within a room through the walls or ill-made joints without the 
influence of wind-currents. In an occupied room this is, however, 
insufficient to keep the air pure, because many of the organic im- 
purities of respired air are molecular, and, therefore, incapable of 
making their way out of the rooms through the walls. 

Perflation means, literally, "blowing through," and, if the di- 
rection and force of air-currents could be regulated, this would, with 
simple mechanical arrangements, be an efficient means of ventilation. 
However, the uncertainty of the force and direction of the wind makes 
this method of ventilation untrustworthy except in warm weather. 

Unequal pressure between the air in a room and that without 
is, within certain limits, an efficient means of ventilation, and is usu- 
ally relied upon in ordinary apartments. When the air in a room 
is heated above the temperature of the external air, either by a fire, 
lights, or by the presence of a number of persons in the room, it ex- 



PRINCIPLES OF VENTILATION. 41 

pands, and part of it finds its way out through numerous crevices 
and bad joints found in all buildings. The air which remains be- 
ing less dense than the external air, the latter enters the room by 
various openings, until the equality of pressure is re-established. 
But as the heating of the enclosed air continues, the process is mom- 
entarily repeated and becomes continuous. 

Although the impurities of respired air (carbon dioxide, or- 
ganic matter) are heavier than the air itself at the same temperature, 
it is a familiar fact that the most impure air in an occupied room 
is always found near the ceiling, the impurities .being carried up- 
ward with the heated air, and that the pure air from without, being 
colder, fills the lower part of the room. 

If the cold, outside air were to be admitted at the bottom of the 
room, and means allowed for the escape of the hot air at the top, the 
conditions of the old health-maxim, to "keep the feet warm and the 
head cool," would be reversed. This would be no less uncomfortable 
than unwholesome. In all plans for natural ventilation, therefore, 
provision must be made to secure a gradual diffusion of the cold, out- 
side air from above, or to have it warmed before it enters the room. 
With a large chimney as an aspirating shaft, 27 with flues at the top 
and bottom of the room, and openings in the walls of the room near 
the ceiling to admit fresh air, sufficient ventilation can be usually 
secured in cold weather, in a room not overcrowded. 

When a room is heated by a furnace, the fresh air is warmed 
before it is introduced, and the foul air escapes either through a ven- 
tilating shaft, a ventilator in the window or wall, or through the 
numerous fissures and other orifices which defective carpentering 
always leaves for the benefit of the health of the occupants. 

The following rules for the arrangement of a system of natural 
ventilation are modified and condensed from Parkes 28 : — 

The apertures of entrance and of exit for the air should be 
placed far enough apart to permit thorough diffusion of the fresh air. 

When the air is brought into a room through slits or tubes in the 
walls near the ceiling the current should always be deflected upward 
by an inclined plane, in order to prevent a mass of cold air from 
descending over the shoulders of the occupants and chilling them. 

The air must be taken from a pure source. 



27 Of course there is really no such thing as a real aspiration, or "sucking 
out" of the air through the chimney or so-called "aspirating shaft." The 
upward movement of the air in the shaft is due to its displacement hy the 
colder or denser air entering the room. 

28 Manual of Practical Hygiene, 6th ed., New York, vol. i, p. 177. 



42 TEXT-BOOK OF HYGIENE. 

The inlet-tubes should be short, and so made as to be easily 
cleansed, otherwise dirt lodges and the air becomes impure. 

Inlets should be numerous and small, to allow a proper distribu- 
tion of the entering air. 

Externally, the inlets should be partially protected from the 
wind, to prevent strong draughts; they should also be provided with 
valves to regulate the supply of air. 

If the air cannot be warmed, the inlets must be near the ceiling; 
if it can be heated, it may enter near the floor. 

The air may be warmed by passing it through boxes containing 
hot water or steam coils, by passing it through chambers around 
grates or stoves, or heating it in a furnace. 

In towns or manufacturing districts the air should be filtered 
before allowing it to enter the room. Thin flannel or muslin spread 
over the openings answers very well as filtering material. 

Outlets should be placed at the highest point of the room and 
should be protected from the weather. An opening into the chimney 
near the ceiling will answer well in many cases. 

In one-story buildings, ridge-ventilators make the best outlets. 
The entrance of snow and rain must be prevented by suitable ar- 
rangements. 

A small space or slit between the horizontal bars of the upper 
and lower window-sash will admit sufficient air in a proper direc- 
tion in small rooms, even when the window is shut. 

In all rooms, howsoever ventilated, doors and windows should 
be often opened to permit a thorough -flushing of the interior with 
fresh air. 

For large buildings, hospitals, schools, theatres, ships, and mines, 
two systems of artificial ventilation are in use. One operates by 
extracting the foul air by means of fans, the other by forcing in 
fresh air, allowing the impure air to find its way out as best it may. 

Rotating cowls on the tops of chimneys may be used to increase 
the aspirating power of the air; in this way the natural force of the 
wind may be utilized for ventilation of rooms or buildings of mod- 
erate size. 

Further details upon the practical application of these prin- 
ciples will be given in succeeding chapters of this work. 



QUESTIONS TO CHAPTER I. 

AIR. 

What is the composition of the atmospheric air? Is the mixture a 
chemical or mechanical one? What constituent is the most constant in pro- 
portion, and what ones most variable? Wliat are the causes and limits of 
variation in the composition of the air? Has this variation any effect upon 
health? 

How is the general uniformity of composition maintained? What is the 
relation of the oxygen and carbon dioxide to plant and animal life and to one 
another ? 

What is the depth of the atmosphere? What is its weight, and how is 
this measured? How may you determine the altitude of any place above the 
sea-level? 

What effect has temperature on barometric pressure? What effect has 
moisture and why? Whence does the air derive its warmth? Where is the 
atmosphere warmest? 

What is the relation between the temperature and humidity of the air? 
What is meant by "absolute" and "relative" humidity? How is each always 
designated? What is meant by "saturation"? 

What causes motion in air or wind? What conditions of the atmosphere 
probably have relation to, or influence upon, disease ? Why should a sanitarian 
be a practical meteorologist? 

What are the physiological effects of diminution of atmospheric pressure ? 
What may aggravate these effects? To what are they due? Can the human 
body become accustomed to them? What name is given to this physiological 
disturbance? What diseases will probably improve in a rarefied atmosphere, 
and what ones will not? 

What are the effects of increased atmospheric pressure upon the organ- 
ism? Is there any danger of fatal results? Have the diurnal variations of 
pressure any effect upon the body in health or in disease? 

What effect has high temperature upon health? What diseases are more 
frequent in hot weather and in hot climates? 

What peculiar affection seems to be caused or favored by long-continued 
exposure to cold? What are some of the acute effects of cold? What effect 
has the relative humidity in the production of these diseases? Indicate and 
explain a possible relationship of causation between coryza or influenza, bron- 
chitis and pneumonia. Is this altogether substantiated by statistics? Is low 
temperature the only cause of pneumonia? 

What part has the relative humidity in the production of certain dis- 
eases ? 

What is the general rule as to the effect of winds or air-currents upon 
health? Name some apparent exceptions to this rule. Has the season any 

(43) 



44 TEXT-BOOK OF HYGIENE. 

thing to do with the morbidity and mortality from different diseases? Give 

examples. 

What is the average proportion of carbon dioxide in the atmosphere? 
What should be the maximum limit permissible in dwellings? Is this limit 
often exceeded? When exceeded, to what are the evil effects upon health 
probably due? How much carbon dioxide alone may be present in the atmos- 
phere without producing any apparent ill effects? 

When and where in the out-door atmosphere is the proportion of carbon 
dioxide greatest? In what way may this be explained? 

What are the products of respiration and perspiration, and which of 
these is most harmful to health? What evidence have we to that effect? 
Have we any evidence that the respiratory carbon dioxide alone is harmful to 
health? Where there is a moderate degree of respiratory pollution, what 
are some of the symptoms usually produced thereby? In the production of 
what especial disease has impure air a decidedly causative influence? 

Which is the more dangerous to health, carbon monoxide or carbon diox- 
ide? Of what gases is the former an ingredient? How does it produce its 
harmful effects? 

Have sulphuretted and earburetted hydrogen any effect upon health? If 
so, in what proportions must they be in the atmosphere? Has ammonia, in the 
proportion in which it is usually found in the atmosphere, any bad effect upon 
health? 

What is sewer-air or sewer-gas, and what are some of its constituents? 
In what way may it be the cause of infectious disease? Will the continued 
breathing of air polluted with sewer-gas affect health, and, if so, what symp- 
toms may be caused thereby? 

Is there any positive evidence that the emanations from cemeteries, bone- 
yards, etc., are harmful to health? 

What diseases may be produced by the inhalation of pathogenic micro- 
organisms carried by the air? 

How may the presence of ozone in the air be demonstrated? Upon what 
does the test depend? How might an approximate quantitative test of ozone 
be made? 

How may the suspended impurities in the atmosphere be collected for 
examination? Which method requires the least apparatus, etc.? How may 
the character and nature of the suspended particles be determined? How may 
a quantitative bacteriological examination be made? What are some of the 
advantages of Dr. Dixon's apparatus? Of the sugar-filter method? How may 
pure cultures of micro-organisms in the air be obtained? 

How may the quantity of organic matter in the air be determined? Why 
do we determine the proportion of carbon dioxide in the air? What is Wol- 
pert's method for finding the percentage of this gas, and how may this method 
be simplified? Upon what does this test depend? What precautions must 
be observed in making the test? What is the Angus Smith method for deter- 
mining the proportion of carbon dioxide? How may it be improved? What 
is the use of the phenolphthaleine in the solution? How is the percentage 
of carbon dioxide calculated? How is the alkaline solution to be prepared? 

Upon what does Pettenkofer's method depend? What apparatus and 
reagents are required? Why must the lime-water be standardized each time? 



QUESTIONS TO CHAPTER I. 45 

What is the value of the oxalic-acid solution? What are some good indicators 
to use in this test? Why is just twice the volume of lime-water introduced 
into the bottle that is afterward taken from it and tested? What are some of 
the advantages and disadvantages of baryta-water in comparison with lime- 
water ? 

How may the quantity of ammonia in the atmosphere be determined? 
How may the presence of other gases be shown? What is the usual test for 
carbon monoxide? Upon what is Vogel's test based? Is it a delicate one? 
Why is it usually not necessary to make a quantitative examination of the 
carbon monoxide? 

Ventilation.— How much oxygen does an adult human being at rest ordi- 
narily take from the air, and how much carbon dioxide does he add to it in 
twenty-four hours? What percentage of carbon dioxide in the air indicates 
the greatest amount of organic impurity from respiration, etc., consistent with 
health? How much fresh air per hour is, therefore, needed by each individual 
to maintain this state of purity? Will sick persons need more fresh air than 
the well? Why? 

What is meant by ventilation? What should be excluded from the term? 

What matters must a proper system of ventilation consider? What gov- 
erns the amount of cubic space that can be allotted to each individual? What 
should be the minimum air-space for the well, and what for the sick? What 
should be the floor-space for each person, and why? From what kind of a 
source must the air for a ventilation supply be taken? 

What is the difference between natural and artificial ventilation? What 
are the forces acting to produce natural ventilation? What is meant by dif- 
fusion? Why is it insufficient for ventilating an occupied room? What is 
meant by perflation? Why cannot it be used alone for ventilation? Upon 
what does the inequality of atmospheric pressure depend? Why is it the most 
valuable of the forces of natural ventilation? 

In what part of an occupied room is the most impure air found, and 
why? 

What precautions must be observed in all plans for natural ventilation? 
What makes the air from a room pass up a chimney? When a room is heated 
by a hot-air furnace, how does the foul or used air escape? What rules may 
be laid down for the arrangement of a system of natural ventilation? 

Where should the fresh-air inlets of a room be located? How may the 
air be warmed before bringing it into the room? How should the inlet-tubes 
be arranged? Where should the outlets of a room be located? 

What systems of artificial ventilation may be employed for large build- 
ings or rooms ? By what appliances may we make use of winds for ventilating 
purposes ? 



CHAPTER II. 

WATER. 

Physiologists teach that nearly two-thirds of the tissues of the 
animal body consist of water. Inasmuch as this water is constantly 
being lost by evaporation from the skin, exhalation by the lungs, and 
excretion through various organs, it is evident that the loss must be 
constantly supplied if the functions of life shall be properly per- 
formed. 

It appears probable that certain diseases are at times spread 
through the agency of insufficient or impure drinking-water. It is 
therefore a matter of very great importance to have a definite knowl- 
edge of what constitutes a pure and sufficient supply of water, and 
how best to secure it, to be able to detect its conditions of purity and 
impurity, and to know how to maintain the former and avoid the 
latter. It will be necessary to consider in detail, therefore, the 
quantity of water required by each individual for the maintenance 
of health, the sources whence water is obtained, how it should be col- 
lected and stored to the best advantage, the impurities likely to be con- 
tained in it, and the methods of keeping it pure, or of purifying it 
when it has become polluted or vitiated in any manner. 

THE QUANTITY OF WATER REQUIRED BY HUMAN 
BEINGS. 

Dr. Parkes, after a number of experiments, concluded that a 
man of the English middle class, "who may be taken as a fair type of 
a cleanly man belonging to a fairly cleanly household/' uses about 
twelve gallons of water per day. This covers all the water needed, 
including a daily sponge bath. Dr. DeChaumont estimates 1 that 16 
gallons should be the daily allowance. By order of the British War 
Department, 15 gallons of water are allowed to each soldier daily. 
In very many instances this quantity cannot be furnished, but in 
such cases there necessarily results some deficiency in cleanliness. It 
is probable that among the poorer classes, especially where a large 
supply of water is not convenient, the quantity used is not over one- 
fourth of the above estimate. 



1 Parkes' Hygiene, 6th ed., New York, vol. i, p. 5. 
(46) 



QUANTITY OF WATER REQUIRED. 



47 



Parkes and Kenwood 2 give the average daily quantities per 



head :- 



Household 



Table IV. 

Fluids as drink 0.33 

Cooking 0.75 

Personal ablution 5.00 to 10.00 

Utensils and house washing 3.00 

Clothes washing (laundry) 3.00 

Water closets 5.00 

Trade and manufacturing 5.00 

Cleansing streets 5.00 

Public baths and fountains 5.00 

Flushing and cleansing sewers 5.00 

Extinguishing fires 5.00 

27.08 to 32.08 



Municipal 



In American cities the daily consumption is much greater, as 
seen from the following table: — 

Table V. 
Showing Consumption of Water in 105 American Cities. 



City and State 



Akron, Ohio p 

Altoona, Pa m 

Anderson, Ind m 

Atlantic City, N. J m 

Augusta, Georgia m 

Atlanta, Georgia m 

Battle Creek, Mich m 

Boston, Mass m 

Buffalo, N. Y m 

Burlington, Iowa p 

Binghamton, N. Y m 

Brocton, Mass m 

Camden, N. J m 

Cambridge, Mass m 

Cincinnati, Ohio m 

Chicago, 111 m 

Cleveland, Ohio m 

Charleston, S. C m 

Council Bluffs, Iowa . . p 

Denver, Colo . . p 

Detroit, Mich m 

Danville, 111 p 

Davenport, Iowa p 

Dayton, Ohio m 

Duluth, Minn m 

Danbury, Conn m 

Easton, Pa p 



Population 



46,733 


1 
'03) 


52,000 


'03) 


20,178 


('00) 


32,272 


('03) 


41,283 


('03) 


96.550 


'03) 


18,563 


COO) 


594,618 


('03) 


381,403 


('03) 


23,201 


('00) 


39,647 


'00) 


50,000 


'05) 


79,811 


('00) 


98,444 


'03) 


340,000 


'03) 


1,873,880 


('03) 


444,600 


'05) 


55,807 


'00) 


25,802 


'00) 


147,111 


'03) 


369,805 


'05) 


16,354 


('00) 


37,768 


('03) 


92,716 


('03) 


57,397 


('03) 


16,537 


('00) 


23,238 


('00) 



D ily 

Consumption 

Gallons 



7,500,000 
4,500,000 
2,000,000 
5,250,000 
5.500.000 
7,500,000 
1,133,000 
83,000,000 
125,000,000 
2,000,000 

2,000,000 

12,000,000 

8,775,000 

48,536,000 

175,000,000 

61,572,000 

3,070,000 

2.500,000 

32,000,000 

60,212,539 

2.500,000 

4,000,000 

7.000,000 

5,000,000 

2,000.000 

2,000,000 



Per 
Capita 3 
Gallons 



137 

90 

66 

138 

110 

60 

60 

145 

320 

80 



36 
160 

89 
137 
200 
138 

55 

85 
200 
168 
157 
100 

66 

85 
125 

87 



2 Hygiene and Public Health, 1902. 

3 The per capita is based on the number of consumers. 



48 



TEXT-BOOK OF UYGIKXK. 



Table V. — (Continued.) 
Showing Consumption of Water in 105 American Cities. 



City and State 



Elmira, N. V p 

Erie, Pa m 

Evansville, End m 

Fort Smith. Ark p 

Fall River. Mass m 

Fond du Lac, Wis p 

Fort Wayne, Ind m 

Fitehburg. Mass m 

Grand Rapids, Mich m 

Harrisburg, Pa m 

Hartford, Conn m 

Haverhill, Mass m 

Henderson, Ky m 

Houston, Texas p 

Holyoke, Mass m 

Indianapolis, Ind p 

Johnstown, Pa p 

Jamestown, N. Y p 

Kansas City, Mo m 

Kingston, N. Y m 

Lowell, Mass m 

Los Angeles, Cal m 

Lynn, Mass m 

Louisville, Ky m 

Lincoln, Neb m 

Manchester, N. Y m 

McKeesport, Pa m 

Minneapolis, Minn m 

Milwaukee, Wis m 

Memphis, Tenn p 

Muskegon, Mich m 

Norfolk, Va m 

New Bedford, Mass m 

New Orleans, La p 

New Albany, Ind p 

Nashville, Tenn m 

New Haven, Conn p 

Oshkosh, Wis p 

Paterson, N. J p 

Peoria, 111 m 

Pittsburg, Kans p 

Portland, Me p 

Portland, Ore m 

Quincy, Mass m 

Quinev, 111 p 

Reading, Pa m 

Rochester, N. Y m 

Roanoke, Va p 

Rock Island, 111 m 

Rushville, Ind m 

Richmond, Va m 

Salem, Mass m 

Saginaw, Mich m 







Daily 


Per 


Population 


Consumption 


Capita 






Gallons 


Gallons 


37,106 


('03) 


5,000,000 


125 


56,363 


('03) 


| 10,000.000 


168 


61,482 


('03) 


9,000,000 


145 


11,587 


COO) 


2.225.000 


125 


114,004 


('03) 


4,000,000 


36 


20.000 


('05) 


1.250,000 


63 


48,031 


('03) 


4.000.000 


84 


34.378 


('03) 


3.000,000 


90 


93.679 


('03) 


14.000.000 


139 


52.951 


('03) 


8,750,000 


135 


100,000 


('05) 


6,150,000 


67 


38.987 


('03) 


4,100,000 


111 


10.272 


('00) 






75,000 


('03) 


10,000,000 


134 


50,831 


('05) 


5,000,000 


100 


197,555 


('03) 


18,750,000 


94 


39,980 


('03) 


8,000,000 


200 


22,892 


('00) 


2,250,000 


1C0 


250.000 


('05 ) 


19,200,000 


77 


25,516 


('03 ) 


3,500,000 


200 


100,150 


('03) 


5,500,000 


52 


116,420 


('03) 




165 


72,350 


('03 ) 


5,500,000 


64 


215,722 


('03 ) 


18,000,000 


72 


44,158 


C03) 


18,000,000 


36 


60,845 


('03) 


3.500.000 


50 


38,274 


('03 ) 


4,200.000 


90 


214,112 


('03 ) 


18.500.000 


79 


313.025 


('03 ) 


27.000,000 


80 


113,669 


('03 ) 


12.000.000 


100 


20,818 


COO) 


2.900.000 


132 


55.318 


('03) 


6,300.000 


110 


66,000 


('05 ) 


7,000,000 


95 


300.625 


('03 ) 


14.000.000 


47 


20,628 


C00) 


2.000.000 


66 


83,275 


('03) 


13.500.006 


135 


114.627 


C00) 


20.000.000 


150 


29.919 


('03 ) 


2.500.000 


85 


113.217 


('03 ) 


10.500.000 


100 


62,348 


('03 ) 


4.500.000 


72 


10.112 


C00) 


1.000,000 


75 y> 


52,656 


('03 ) 


6.000.000 


110 


98,655 


C03) 


20.000.000 


200 


26.053 


('03 ) 


2,600,000 


103 


37.680 


('03 ) 


1.435.000 


38 


85,051 


('03 ) 


11.000.000 


124 


170,798 


C03) I 


15,238.000 


87 


21,495 


C00) | 


3.000.000 | 


94 


19.493 


C00) 


3.400.000 1 


17 


4.541 


C00) | 


800.000 | 


160 


86.148 


C03) | 


13.000.000 [ 


129 


23,504 


C03) | 


3.300.000 | 


89 


45,543 


('04) | 


10,000,000 | 


200 



QUANTITY OF WATER REQUIRED. 



49 



Table V. — {Continued.) 
Showing Consumption of Water in 105 American Cities. 



City and State 



Sioux City, Iowa m 

Salt Lake City, Utah m 

South Bend, Ind m 

St. Joseph, Mo p 

Somerville, Mass m 

Springfield, Mass. . m 

St. Paul, Minn. . . m 

St. Louis, Mo m 

Springfield, 111 m 

Syracuse, N. Y m 

San Antonio, Texas p 

Taunton, Mass m 

Terre Haute, Ind p 

Toledo, Ohio m 

Utica, N. Y p 

Waterbury, Conn m 

Vincennes, Ind p 

Watertown, N. Y m 

Worcester, Mass m 

Wilmington, N. C p 

Waltham, Mass m 

Washington, D. C m 

Wilmington, Del m 

York, Pa p 

Yonkers, N. Y m 







Daily 


Per 


Population 


Consumption 


Capita 






Gallons 


Gallons 


33,111 


COO) 


1,290,000 


39 


57,138 


('03) 


15,000,000 


200 


40,327 


('03) 


4,000,000 


81 


110,479 


('03) 


6,000,000 


55 


68,090 


('03) 


6,000,000 


89 


74,916 


('05) 


9,700,000 


128 


172,038 


('03) 


9.000,000 


52 


612,279 


('03) 


75,000,000 


125 


36,211 


('03) 


4,470,000 


108 


114,443 


('03) 


12.000.000 


105 


58,016 


('03) 


10,000,000 


170 


32,713 


('03) 


1,750,000 


64 


54,008 


('05) 


4,200.000 


77 


145,901 


('03) 


11,000,000 


69 


60,097 


('03) 


4,000.000 


33 


56.521 


('05) 


6,000,000 


130 


10,249 
21,696 


('00) 






COO) 


4.000,000 


188 


130,207 


('05) 


10,000,000 


rs 


20.976 


COO) 


700,000 


50 


23,481 


COO) 


2,000.000 


80 


300,000 


('05 ) 


65,000,000 


217 


84,000 


('05) 


8,000,000 


95 


36,438 


('03) 


2,850,000 


70 


62.000 


('05) 


6,500,000 


92 



"in" — Municipal, "p" — Private Company. 

This excessive consumption is brought about not so much by 
legitimate use of the water as by waste : negligence and imperfections 
in the supply apparatus, allowing the water to run in the winter to 
prevent freezing of pipes, etc. When it is taken into consideration 
that the cost of pumping water averages from four to five dollars per 
million gallons, and in cities which purify their water-supply the cost 
is from two to three dollars more, the question of waste assumes a 
very important economic phase. In several of the larger American 
cities this problem has been satisfactorily solved by the introduction 
of metres, by means of which the water consumed in each household 
or factory is measured and charges regulated according to the amount 
of water consumed. In Wilmington, Del., the introduction of metres 
has eliminated waste and reduced the consumption to an average of 
100 gallons per capita. This, however, includes the consumption of 
water by *manuf actories. In one of the strictly residential portions 
of the city the per capita consumption averages 30 to 35 gallons daily, 
the' latter being the average amount of water required by a middle- 
class American household. One of the objections to metres is that the 



50 TEXT-BOOK OF HYGIENE. 

very class of persons whom it is desired to induce to nse a plentiful 
supply of water would, from motives of economy, use less than is 
necessary for cleanliness and health. This objection, however, is 
purely hypothetical. Water is the cheapest commodity, and by the 
elimination of waste the cost could be still further reduced. As a 
matter of fact, it is not abundance of water that encourages cleanli- 
ness. "You can lead a horse to the water, but you can't make him 
drink it." Habits of cleanliness should be inculcated in ways other 
than by allowing a wanton waste of water. 

SOURCES OF DRINKING=WATER. 

All water, from whatever direct source obtained, comes origin- 
ally, by precipitation, from the atmosphere. In many places the 
rain- or snow- water is the only source of supply. This is usually 
collected as it falls upon the roofs of buildings and conveyed by 
gutters and pipes to cisterns, where it is stored until needed. 

In Venice, the rain falling upon the streets and courtyards is 
also collected in cisterns after filtering through sand. The cisterns 
used for the storage of water in New Orleans and other Southern 
cities in the United States, where the temperature rarely falls below 
the freezing-point, are generally constructed of wood and placed 
above-ground. Farther north, where it is necessary to protect them 
against the action of frost, they are placed under-ground. These 
under-ground cisterns are usually built of brick. The water from 
cisterns above-ground becomes very much heated in summer, and 
necessitates the use of large quantities of ice to make it palatable. 
The water from the under-ground cisterns is pleasantly cool in sum- 
mer, and is also guarded against freezing in winter. There are, 
however, very serious objections to storing drinking-water in under- 
ground cisterns. These reservoirs are usually placed within a few 
feet of privies and cess-pools, and,. as neither the retaining w r alls of 
the cisterns nor those of the privies are water-tight, it often happens 
that the drinking-water becomes strongly impregnated with the sol- 
uble portions of the excrement, or the products of its decomposition, 
which have drained into the cistern. Personal observations in Mem- 
phis in 1879, as well as the careful chemical analyses made afterward 
by Dr. Chas. Smart, U. S. A., 4 have convinced the author that the 
objections to all under-ground cisterns built of brick, *stone, or 
cement are insuperable from a sanitary point of view. Dr. Smart 



4 Report National Board of Health, 1880, pp. 437-441. 



SOURCES OF DRINKING-WATER. 51 

found over one-half of the under-ground cisterns examined by him 
in Memphis and other cities and towns to be leaky and presenting 
evidence of organic pollution. The water from 31 out of 80 cisterns 
analyzed showed decided contamination by sewage. It would seem 
advisable to prohibit all under-ground cisterns for the storage of 
drinking-water unless they are constructed of iron, which should 
be protected against oxidation by a thorough coating of coal-tar. 
Where any other system of collection and storage is available, how- 
ever, the under-ground cistern should be unreservedly condemned. 

Eain-water collected in the country, away from manufacturing 
districts, is usually quite pure and wholesome. Its taste is, however, 
flat and insipid, owing to absence of carbon dioxide and mineral con- 
stituents. In cities rain-water frequently contains such a large 
amount of organic matter and other impurities, which have been 
washed out of the air by the rain, that it may be unfit for drinking. 
On account of its softness, rain-water is very desirable for washing 
and other domestic purposes. If the statement made in the last chap- 
ter, concerning the presence of organisms in the atmosphere, is remem- 
bered, then it will be evident on a moment's thought that such organ- 
isms, when contained in rain-water, may be the source of disease. The 
putrefaction which so readily takes place in rain-water upon standing 
a few days is caused by certain of the organisms carried down out 
of the lower strata of the air by the descending rain or snow. 

Precipitation is an exceedingly untrustworthy source of water, 
and should never be depended upon when other sources of supply are 
available. Water famines are frequent wherever people are com- 
pelled to rely upon such an uncertain source of supply as rain or snow. 

Eivers and smaller streams probably supply the larger number of 
cities and towns in this country with drinking-water. When care is 
taken to prevent the pollution of the stream above the point whence 
the water is taken, this is usually of fair quality for domestic pur- 
poses. When the river can be tapped near its source, or before a 
'large number of manufacturing establishments can empty their waste 
products into its current, or before it receives the sewage of a consid- 
erable number of inhabitants living on its banks, the water can gen- 
erally be regarded as safe. It is very difficult, however, except in the 
less settled portions of the country, to find these favorable conditions. 

Among the minor objections to the use of river-water for domes- 
tic purposes are the liability of most streams to become turbid in 
times of freshet, and the discoloration of the water from dissolved 
coloring-matters if the stream flows through a marshy or peaty 



52 TEXT-BOOK OF HYGIENE. 

region. These objections are, however, not serious, as nitration will 
readily remove the suspended matters. The coloring-matter is prob- 
ably harmless. The organic matter contained in the water of some 
streams, even when pollution by sewage and manufacturing refuse is 
absolutely excluded, may, however, be the cause of disease. Dr. 
Smart has shown 5 that the water from streams in Nebraska, Wyom- 
ing, and Utah contained organic matter varying in amount from .16 
to .28 parts per million. 6 He thinks the so-called "mountain fever 77 
of the Eocky Mountain region is a malarial fever caused by the large 
amount of organic matter in the drinking-water. 

Dr. G. M. Kober, U. S. A., states that he has frequently drunk 
water from mountain streams which had a perceptible taste of cattle- 
manure, and suggests that as the origin of the ammonia found by 
Dr. Smart in the water of mountain streams. Dr. Kober also regards 
the "mountain fever 77 as a typhoid fever with malarial complications. 7 

The most serious objection to the use of river-water for domestic 
purposes is the employment of streams as carriers of refuse from 
manufacturing establishments, or of the sewage of cities and towns. 
In Great Britain and some parts of the continent of Europe, owing 
to the density of population and the variety and extent of manufac- 
turing industries, many of the streams are in an extremely filthy 
condition. In this country, too, especially in the more thickly settled 
manufacturing districts, the pollution of rivers has increased to a 
degree to seriously jeopardize the health of the people who are com- 
pelled to draw their water-supply from such streams. That the pres- 
ence of such excessive contamination renders the water unsuitable for 
domestic purposes must appear evident. It is probable, however, that 
the most dangerous of the polluting matters are the excreta of human 
beings, especially those of patients suffering from certain specific dis- 
eases, such as typhoid fever or cholera. 

Only a few years ago it was a generally-accepted theory that 
running water, though polluted by sewage, "purifies itself 77 after flow- 
ing a distance of twelve miles, and the comforting and reassuring doc- 
trine is still held by many. Eecent observations point to the con- 
clusion, however, that "no river is long enough to purify itself." A 
certain proportion of the sewage, it is true, undergoes oxidation in 
the presence of light and air and minute organisms, 8 and so becomes 



5 American Journal Med. Sciences, January, 1878, p. 28 et seq. 

6 The source of this organic matter seems to be the melted snow which 
makes up a large portion of the streams. 

7 Report of California State Board of Health for 1886, pp. 48 and 177. 

9 Desinfection, in Eulenburg's Realencyclopaedia d. ges. Heilkunde, vol. iv, 
p. 68. 



SOURCES OF DRINKING-WATER. 53 

changed into other, possibly innocuous, compounds. But at present 
it is not known what proportion or what kind of organic matter does 
undergo this change. Another portion of the impurities is deposited 
upon the bottom and sides of the stream, having been only held in 
suspension, and not dissolved in the water. A portion probably forms 
chemical combinations with other suspended or dissolved matters, and 
is changed into compounds which may be volatile and pass off into 
the air or form insoluble precipitates. 

The remainder is rendered less perceptible or imperceptible by 
dilution. Every stream has sources of inflowing water — feeders — ■ 
which increase its volume, and thus dilute any foreign admixture. 

In view of these facts, the theory of the self-purification of 
streams, as formerly held, can no longer be regarded as true. But it 
is unquestionably true that running water does regain comparative 
purity if the inflow of sewage and other refuse is not excessive. It 
cannot be stated with confidence, however, when a stream, once pol- 
luted, becomes fit to use again. 

The water from fresh-water lakes and ponds is generally to be 
preferred to river-water for domestic use. It is less liable to become 
turbid from time to time, and, except in the case of small ponds, the 
inflow of sewage is not likely to cause fouling of the water to any 
serious extent. When the supply can be drawn from large lakes, as 
is done in Chicago and other cities on the great lakes of the United 
States, no purer or better source can be desired. In these cases the 
point whence the water is taken should be far enough from shore 
to avoid the possibility of sewage contamination. When the water- 
supply is taken from small ponds, all sewage and waste products from 
houses and factories must be rigidly excluded; otherwise, diseases 
attributable to the polluted water are likely to arise* among those 
using the same. 

The water in small lakes and storage reservoirs sometimes be- 
comes offensive in taste and odor. The water-supplies of several of 
the large Eastern cities have at times had a peculiar odor and taste 
somewhat resembling cucumbers. The cause of this odor and taste 
was found to be a minute fresh-water sponge, the Spongilla fluviatilis. 
A still more offensive odor, tersely described as the "pig-pen odor," is 
given to the water by the decay of certain species of nostoc and other 
algae. It is not known that either these vegetable or animal micro- 
organisms, if present, render the water prejudicial to health. 

Ponds are often used as sources of ice-supply. It was formerly 
supposed that in the process of freezing, solid matters in the water 



54 TEXT-BOOK OF HYGIENE. 

wore not included in the block of ice when congealation occurred. 
Recent observations have shown the falsity of this assumption. In 
1\\ an outbreak of acute intestinal disease at Eye Beach, New 
Hampshire, led to an inquiry by Dr. A. H. Nichols, which disclosed 
the fact that the ice used contained a large percentage of organic 
matter. The use of ice from a different source was followed by an 
almost immediate disappearance of the disease. Upon further inves- 
tigation it was discovered that the impure ice had been gathered 
from a small, stagnant pond into which a small brook carried large 
quantities of saw-dust from several saw-mills. The water of the pond 
was loaded with organic matter, and in summer the gases of decay 
arising from it were very offensive. Chemical examination showed 
that the ice from this pond contained nearly 6 quarts of organic matter 
in 100,000, while in pure ice the organic matter amounted to only .3 
part in 100,000. A similar investigation into the character of the ice 
furnished to the residents of Newport, E. I., was made under the 
auspices of the Sanitary Protection Association of that city. The ice, 
which was cut from ponds in the immediate neighborhood of the city, 
was found to contain an excessive proportion of organic matter. 
Large quantities of sewage and other impurities were discharged into 
these ponds. 

Experiments made at various times show that the purification 
of water by freezing is in no sense absolute. A considerable num- 
ber of the bacteria, infusoria, and other organisms remain in the ice 
and retain their vitality, so that when thawed they rapidly multiply. 
In the ordinary process of freezing the upper portion is the purest, 
but if snow or rain fall upon the ice and freeze, this upper layer 
will be found much more impure than the lower. Eational conclu- 
sions from these experiments are, that ice should not be gathered 
from an impure source, and that an early harvest of the ice should be 
encouraged. 

Prudden has shown that typhoid bacilli contained in water are 
not entirely destroyed by freezing, even after remaining in this con- 
dition for 103 days. 

Springs and wells supply the water for most persons not aggre- 
gated in large communities, as cities and towns. Even in the latter 
no inconsiderable quantity of the water used for drinking and domes- 
tic purposes is derived from w r ells. Spring-water usually comes from 
a source at a considerable depth below the surface; that is to say, the 



Report Massachusetts State Board of Health, 1876, p. 467. 



SOURCES OF DRINKING-WATER. 



55 



water has percolated through thick strata of soil before re-appearing 
at the surface. In its passage through the soil it has lost most of 
its organic matter, and perhaps taken up mineral and gaseous con- 
stituents in larger quantities. It may be so strongly impregnated 
with the latter as to vitiate it for ordinary use and to render it val- 
uable as a medicine. Ordinarily, however, spring-water is clear, cool, 
and sparkling, with a refreshing taste and uniform temperature, and 
is in all respects an agreeable and wholesome beverage. 

Springs vary greatly in character. They may be cold, hot, or 
thermal, and boiling or geysers; they may be either superficial or 
deep, and the water may be either pure or polluted, depending on 




Fig. 3. — Showing Formation of Spring. E, Earth. R, Rock. WS, 
Water-bearing Stratum. 18, Impervious Stratum. 8, Spring. 

source or location. The chemical constituents of spring-waters in 
this country vary from waters containing but a few grains of mineral 
substances to the gallon to waters so saturated with mineral matter 
as to be classed as medicinal. 

The various mineral waters in this country are classified by Hay- 
wood and Smith 10 as follows: — 



Group. 



Thermal 

Nonthermal 



Class. 



I. Alkaline 



II. 



Alkaline- 
saline 



III. Saline 



IV. Acid 



Table VI. 

Subclass 
f Carbonated or 
j bicarbonated 
j Borated 
[ Silicated 
f Sulphated 
< Muriated 
( Nitrated 
f Sulphated 
\ Muriated 
I Nitrated 

Sulphated 

Muriated 



Sodic 
Lithic 
Potassic 
Calcic 
Magnesic 
Ferruginous 
Alumnic 
Arsenic 
,Bromic 
Iodic 
[Silicons 
Boric 



'Nongaseous 
Carbondioxated 
Sulphuretted 
Azotized 
Carburetted 
I Oxygenated 



Bureau of Chemistry, Bui., 91. 



56 TEXTBOOK OF HYGIENE. 

Under this classification the mineral waters on the market may 
be arranged as follows: — 

Alkaline Bicarbonatcd Sodic. — Augusta White lithia water. Gey- 
ser Jefiress lithia water. Manitou water. Powhatan water. Thomp- 
son's bromin and arsenic water. 

Alkaline Bicarbonatcd Magnesic. — Osceola water. 

Alkaline Bicarbonatcd Calcic. — Allouez water. Augusta White 
lithia water. Bear lithia water. Crocket arsenic lithia water. Gol- 
indo lithia water. Great Bear water. JefTress lithia water. London- 
derry lithia water. Manitou water. Mardela water. Massanetta 
water. Missisquoi. Osceola water. Otterburn water. Poland water. 
Powhatan water. Eubino Healing Springs water. Sublett lithia 
water. Yitan water. 

Alkaline Bicarb onated Ferruginous. — Mardela water. 

Alkaline-saline Muriated Sodic. — Carlsbad water. Champion 
water. Chief water. Congress water. Hathorn water. High Eock 
water. Lincoln water. Magnetic water. Peerless water. Gitche 
Crystal Spring water. Seltzer water. Sheboygan water. Vichy 
water. White Eock lithia water. 

Alkaline-saline Muriated Potassic. — Gitche Crystal Spring water. 

Alkaline-saline Muriated Calcic. — Carlsbad water. Champion 
water. Chief water. High Eock water. Lincoln water. Magnetic 
water. Peerless water. Seltzer water. White Eock lithia water. 
Sheboygan water. 

Saline Sulphated Sodic. — Pluto concentrated water. 

Saline Sulphated Magnesic. — Veronica water. 

Saline Sulphated Calcic. — Berry Hill d} T spepsia water. Bedford 
mineral water. Buffalo lithia water. Geneva lithia water. Tate 
epsom water. 

Saline Muriated Sodic. — Arondack ' water. Blue Lick water. 
Cherrydale water. Deep Eock water. Mount Clemens water. Star 
water. Victoria water. Webster Springs salt sulphur water. 

Saline Muriated Calcic. — Cherrydale water. 

Acid Sulphated Aluminic. — Eockbridge alum water. Walla- 
whatoola water. 

Eegarding the effect of mineral waters on the human organism 
both in health and disease, Haywood and Smith 11 present the follow- 
ing summary : — 

Carbonated or Bicarbonatcd Alkaline Waters. — Stimulate the se- 
cretions of the digestive tract, neutralize hyperacidity of the stomach, 

n Loc cit. 



SOURCES OF DRINKING-WATER. 57 

increase metabolism, dissolve uric acid and uric acid deposits, increase 
the flow of urine, and correct acidity of the latter. They are, there- 
fore, of value in catarrhal conditions of the mucous membranes, rheu- 
matism, gout, diabetes, etc. 

Sodic Carbonated and Bicarbonated Alkaline Waters. — Increase 
metabolism, dissolve uric acid, and allay irritation of the mucous 
membrane of the urinary tract. They are useful in acid dyspepsia, 
rheumatism, gout, and diabetes. 

Potassic Carbonated and Bicarbonated Alkaline Waters. — Have 
very much the same action as the sodic carbonated. Their chief use is 
in the treatment of calculi. 

Liihic Carbonated and Bicarbonated Alkaline Waters. — These are 
active diuretics and form soluble urates. They are used in the treat- 
ment of rheumatism, rheumatic tendencies, and gout. In cases of 
gravel and calculi they are a' so valuable disintegrating agents. 

Magnesic Carbonated and Bicarbonated Alkaline Waters. — Act as 
mild laxatives, and are perhaps the best of all the alkaline waters in 
correcting an acid condition of the stomach and curing sick headache 
caused by constipation. They favor the solution of uric acid, are val- 
uable agents in breaking up deposits in the bladder, and are much used 
in catarrhal conditions of the mucous membrane or the urinary organs. 

Calcic Carbonated and Bicarbonated Alkaline Waters. — This 
class of waters produces constipation and decreases the secretions. 
Very obstinate cases of chronic diarrhea have been cured by a sojourn 
at a spring rich in calcium bicarbonate. Uric acid gravel and calculi 
are also disintegrated and eliminated by the free use of these waters. 
Ferruginous Bicarbonated Alkaline Waters. — Increase the amount 
of hemoglobin and in connection therewith increase the temperature, 
pulse, and weight. They also increase the appetite and reduce intes- 
tinal activity. They give excellent results as a tonic, and find their 
principal application in anemia and general debility. Prolonged use 
results in constipation and derangement of the digestion. 

B orated AlkaHne Waters. — They act as antacids. They promote 
the menstrual flow and may be used in catamenial irregularities. 

Muriated Alkaline-saline Waters. — They increase the flow of 
urine and the excretion of uric acid. Are especially valuable in the 
treatment of catarrhal conditions of the mucous membrane of the 
stomach, intestines, biliary passages, and urinary tract. 

Sulphated Alkaline-saline Waters. — They act as diuretics. In 
large quantities they act as purgatives by increasing the peristaltic 
movement and liquefying the intestinal contents. Valuable in the 



TEXT- BOOK OF HYGIENE. 

treatment of catarrhal conditions of the mucous membrane and in 

obesity. 

Muriated Saline Waters. — Stimulate the secretion of the stom- 
ach, increase digestion, favor a better absorption of foods, and act as 
diuretics. 

Sodic Muriated Saline Waters. — Increase the flow of gastric 
juice, improve the appetite, increase the flow of urine and excretion 
of urea. Also prevent putrefactive changes in the intestines. 

Potassic Muriated Saline Waters. — Action very much like that 
of sodium salt. 

Lithic Muriated Saline Waters. — Same as above, with an intensi- 
fied diuretic action due to the lithium. 

Calcic Muriated Saline Waters. — Act as a tonic, increase the flow 
of urine, sweat and bile, and are used in scrofula and -eczema. 

SuJphated Saline Waters. — These waters are laxative or purga- 
tive, according to the amount taken. Are indicated where long-con- 
tinued intestinal stimulation is desired without stimulation of the 
vascular system. 

Sodic and Magnesic Sulpliated Saline Waters. — Act as laxatives 
in small, and purgatives in large, doses. Increase flow of intestinal 
fluids and urine, also excretion of urea. Are of great service in elim- 
inating syphilitic, scrofulous, and malarial poisons from the system, 
in throwing off mercury and other poisons. Useful in the treatment 
of obesity, derangement of the liver, and B right's disease. 

Potassic Sulpliated Saline Waters. — Same effect as above. 

Calcic Sulpliated Saline Waters. — Have no well-known action. 

Ferruginous Sulpliated Saline Waters and Aluminic Sulpliated 
Saline Waters. — Iron and aluminum usually occur together when 
either is present as a predominating constituent in sulphated saline 
waters. These are practically always acid and their action is best 
considered under the sulphated acid group. 

Nitrated Saline Waters. — Only one spring of this kind found. 
Action has not been determined. 

Acid Waters. — Principally composed of the ferruginous-aluminic 
sulphated classes, although there are a few acid springs which contain 
comparatively little iron and aluminum, but quite large amounts of 
calcium, sodium, or magnesium. These waters are used in relaxed 
conditions of the mucous membranes, especially in diarrhea and dysen- 
tery. They are also used in the treatment of exhausting night-sweats 
and impoverished condition of the body brought about by intemper- 
ance or specific diseases. Locally, they are used in the treatment 



SOURCES OF DRINKING-WATER. 59 

of inflamed or relaxed conditions of the mucous membrane such as 
are found in conjunctivitis, chronic vaginitis, etc. Have the usual 
effect of all iron waters, but when desired as a tonic it is best to give 
the ferruginous carbonated water, as the latter is more readily ab- 
sorbed and assimilated. 

Iodic and Bromic Waters. — Act as alteratives. Stimulate the 
lymphatic system to greater activity and promote absorption in all 
tissues. Indicated in the treatment of scrofula, syphilis, goitre, 
chronic exudations, etc. Also favor the elimination of mercury and 
other metallic poisons. The bromic waters also act as sedatives. 

Arsenic Waters. — Act as alteratives, increase the appetite and 
digestion, and improve the general nutrition of the body by increas- 
ing the secretions of the gastro-intestinal mucous membrane and at 
the same time checking katabolism. Especially valuable in the treat- 
ment of anemia and a number of skin diseases. Also indicated in 
chronic malaria, neuralgia of anemic origin, scrofula, etc. 

Silicious Waters. — Precise action unknown. Have been said to 
be useful in cancer and to have caused the disappearance of albumin 
and sugar from the urine. 

Azotized and Oxygenated Waters. — On account of slight solu- 
bility neither nitrogen nor oxygen occurs in waters in very large 
quantities. They possess no medicinal value. 

Carbondioxated. Waters. — Increase the flow of saliva and intes- 
tinal fluids, also increase the peristaltic movement of the stomach 
and thereby improve digestion. Also tend to increase the flow of 
urine. Obstinate cases of nausea are often relieved by these waters. 

Carburetted Waters. — Sometimes occur in coal and natural gas 
regions. Are not known to have any medicinal value, but are usually 
considered unfit for drinking purposes. 

Sulphuretted Waters. — Increase the action of the skin, intestines, 
and kidneys. Also possess a decided alterative effect. Have been 
used in the treatment of syphilis, chronic metallic poisoning, rheu- 
matism, and gout. They have also given excellent results in many 
skin diseases, hyperhemia of the liver, and in catarrhal conditions of 
the pharynx, larynx, and bronchi. 

The great demand for spring-waters, especially mineral waters, 
has called forth a supply of all kinds of spring-waters, good, bad, and 
indifferent. In many cases the claims made by the promotors are so 
extravagant as to class the water among the rankest of patent medi- 
cines. The United States Bureau of Chemistry, therefore, has done 
a most valuable service to the people and the medical profession by 



60 



TEXT-BOOK OF HYCIENE. 



analyzing the more popular mineral waters. The following table 
shows the results of some of these analyses, compiled from Bulletin 

NO. SUI- 
TABLE VII. 
Showing Analyses of Some of the 3Iore Popular Mineral Waters. 





cj" 






















a 


CO 


as 




-2 




<x>* 










a 


"E 


In 


T» 


Eh 

o 


13 


12 


ai 


V 


(U 






















03 
.3 




<j 


fc 


5 


3 


O 


o 


2 


'C 


-d 


o 

B 

a 
< 


2 

c 

a 

3 


in 

3. 
&0 


to 
OS 

a 

to 


« 




a 

3 

'a 
o 


o 

a 


U 

a 

3 


3 
o 

a 


a 

3 


"3 

a 


© 


o 


c 


6JD 


a 
a 


ic 


e3 

O 


£ 




-3 


h 


<$ 


fc 


£ 


C 


< 


1-1 


P-, 


m 


Ph 


X 



Parts per Million, 





,008 


.051 


1.33 


.001 


.45 


0.24 


(a) 


4.6 


46 




5.3 




(Calcic Bicarb. Alkaline) 






Veronica Water 

(Magnesic Sulphated Sal.) 


.08 # 


3.05 


392.8 





.25 


.24 




169.5 


3,170 


(a) 


802.7 


14,151.4 


Bedford Mineral Water . . 
(Calcic Suiphated Saline) 


.014 


.008 


.05 


Tr. 


.85 


.015 


Tr. 


9.3 


9.2 




29 


686.1 


Geneva Lithia Water . . . 
(Calcic Sulphated Saline) 


.015 


.015 


.10 


Tr. 


.55 


.048 


.6 


7.6 


330.4 


Tr. 


2.8 


575 3 


Buffalo Lithia Water . 
(Calcic Sulphated Saline) 


.035 





.50 


Tr. 


.60 


.114 


Tr. 


70 


12 




77.7 


31.7 


Vitau Table Water 

(Cal ic Bicarb. Alk.) 





.05 


.20 





.45 




(a) 


10 5 




Tr. 


14.9 






.01 


.04 


20 


Tr. 


.30 


.03 


Tr. 


32 


17 5 






11 


(Calcic Bicarb. Aik.) 






Londonderry Lithia Water 
(Calcic Bicarb. Alk.) . . 


.015 


.075 


.66 


Tr. 


.90 


.048 


Tr. 


5.5 


.5 




11,2 




White Rock Lithia Water . 


.04 


.09 


10 


.005 


.50 


.125 


76.4 


5.7 


573.6 




49.6 




Bear Lithia Water . . . 
(Calcic Bicarb Alk.) 


.02 


.04 


.2 


T, 


.25 


.063 


Tr. 


31 


1.2 


Tr. 


4.3 




Massanetta Water . . 
(Calcic Bicarb. Alk.) 


.175 


.054 


.5 


.001 


.45 


.519 


(a) 


2.9 











Otterburn Lithia Water . 
(Calcic Bicarb Alk. ) 


.065 


,027 


Tr. 


001 


.70 


207 


.28 


3.6 


43 




4 1 





Tr., Trace; (a)„ Heavy Trace. 



SOURCES OF DRINKING-WATER. 61 

The above table shows how several of the high-priced and much- 
vaunted lithia waters are such only in name, while some of the sup- 
posedly pure spring-waters are no better than water from an average 
farm-spring. 

The character of well-water is often justly open to grave suspicion. 
Being derived from those strata of the soil which are most likely to 
be contaminated by the products of animal and vegetable decompo- 
sitions, the unwholesomeness of the water is inversely proportional 
to the degree of saturation of the soil with the products of decay. It 
has been found by experiment that, when organic matter largely 
diluted with water is allowed to percolate through soil, it undergoes 
a gradual decomposition in the presence of certain minute organisms, 
nitrates and nitrites being formed at the expense of the ammonia 
and other organic combinations. If, however, the soil is saturated 
with organic matter in excess, and in a state of concentration, putre- 
faction takes place, and the conversion of the organic matter into 
nitrates and nitrites is retarded. 

Deep or Artesian Wells. — The name artesian is derived from the 
province of Artois, France, where these wells were sunk centuries ago. 
They are formed when a boring taps a water-bearing stratum con- 
fined between two impervious geological formations. This water- 
bearing stratum forms a subterranean reservoir which is fed by the 
percolation of the surface at some point where the upper impervious 
stratum is either fissured or absent. This is known as the catchment 
area. This area may be near or far from the point where the well is 
sunk and it may be subject to pollution, and there is, therefore, no 
absolute assurance that because a well is deep the water is always 
pure. Sedgwick and Prescot found the following numbers of bac- 
teria in a series of deep wells in Massachusetts :— - 





Table VIII. 




Depth of Well 




Number of Bacteria Per 


in feet. 




Cubic Centimetre. 


100 




30 


193 




269-254 


213 




101-106 


254 




150-135 


377 




48-54 


454 




205-214 



Pfuhl, a well-known German authority, cites an instance of pol- 
lution passing through 180 feet of gravel. The chief objection to 



62 TEXT-BOOK OF HYGIENE. 

artesian wells is their high contents in mineral substances, which im- 
part to the water a permanent hardness. In some regions the amount 
of iron is so great as to act destructively on the pipes. Thus, in the 
town of Gloucester, N". J., the artesian wells which supplied that town 
with water had to be abandoned, owing to the excess of iron in the 
water. 

The following analyses of the water from the four artesian wells 
in Gloucester were made by Messrs. Hamlin and Morrison: — 

Table IX. 

Parts Per Million. 

Well Number 12 3 4 

Calcium carbonate 45 21 00 00 

Magnesium carbonate 25 19 17 12 

Calcium sulphate 51 49 65 73 

Sodium chlorid 9 11 18 16 

Iron oxid and aluminum 14 11 22 62 

Matter insoluble in acid 00 00 32 30 

Volatile and inorganic matter 28 6 76 30 

Nitrates 00 00 00 00 

Nitrites 00 00 00 00 

Iron 9 7 9 14 

Total solids 172 117 220 223 

The quantity of water to be obtained from artesian wells is very 
m uncertain, depending, as it does, on the extent of the catchment area, 
the rainfall, and the number of taps along the subterranean water- 
course. In some localities it may be impossible to obtain an artesian 
supply, and again the supply may be large at first and gradually 
diminish. 

Drinking-water is sometimes procured by melting snow or ice. 
It is not probable that water derived from these sources is unwhole- 
some, although there is strong popular prejudice against it. Ice and 
snow may, however, contain large amounts of impurities, as already 
referred to, and be for this reason unfit for use. 

The following qualities are desirable in water for drinking and 
domestic purposes: — 

1. The water should be colorless, transparent, sufficiently aerated, 
of uniform temperature throughout the year, and without odor or de- 
cided taste. 

2. The mineral constituents (magnesium and lime salts) should 



IMPURITIES IN WATER. 63 

not be present in greater proportion than 4 or 6 parts per 100,000. 
More than this gives to water that quality known as "hardness." 

3. There should be but little organic matter present, and no liv- 
ing or dead animal or vegetable organisms. 

4. The water should be almost free from ammonia and nitrous 
acid, and should contain but very small quantities of nitrates, chlor- 
ides, and sulphates. 

5. It should contain less than one milligramme of lead per litre. 
A larger proportion than this is likely to be followed by lead poisoning. 

6. It should contain no pathogenic bacteria and but few water 
bacteria. 

IMPURITIES IN WATER. 

The transparency and the color of water are affected by the 
presence of suspended or dissolved mineral or organic matters. If, 
after standing for a time, the water deposits a sediment, this is de- 
pendent upon insoluble matters. If the sediment turns black when 
heated in a porcelain capsule over an alcohol or gas flame it contains 
organic matter. If the sediment or residue effervesces upon the ad- 
dition of hydrochloric acid the presence of carbonates is indicated. 
Water may be colored by metallic salts or by vegetable matter. It 
may also contain large quantities of mineral or organic matter, or 
even living organisms, without especially diminishing its transparency. 
For example, the ova of tape-worms may exist in water in considerable 
numbers and yet remain perfectly invisible except under the micro- 
scope. 

The presence of sulphur compounds, or of various vegetable and 
animal organisms (sponges, algae, etc.), may give to water an un- 
pleasant odor and taste. In the oil regions of this country most of 
the drinking-water is contaminated with petroleum, which is very 
disagreeable to one unaccustomed to it. It is not probable that the 
small quantities of the oil imbibed with the water have any deleterious 
influence upon the organism. 

Many works on hygiene fix a limit to the amount of solid matter 
allowable in drinking-water. The International Congress of Hygiene, 
at Brussels, fixed the limit at 50 parts in 100,000. It is impossible,' 
however, to say of any particular specimen of water that its content 
of solid matter, whether organic or mineral, will be prejudicial to 
health, without trial. At the same time it is prudent to reject all 
waters containing a considerable proportion of solid organic matter, 



G4 TEXT-BOOK OF HYGIENE. 

as determined by the degree of blackening on heating the sediment or 
residue after evaporation, or by determination of nitrogen. 

The hardness of water is due to the presence of earthy carbonates, 
or sulphates, or both. If the hardness is due to carbonates it is dissi- 
pated by heat, as in boiling the water; the carbon dioxide is driven 
off, and the base (calcium or magnesium oxide) is precipitated upon 
the bottom and sides of the vessel. This is termed "temporary hard- 
ness." The hardness due to the presence of earthy sulphates is not 
removed upon heating the water, and is termed the "permanent hard- 
ness." The hardness depending upon both the carbonates and sul- 
phates is called the "total hardness." 

The proportion of the above-mentioned earthy salts present in 
a given specimen of water is determined by what is called the soap 
test. This test depends upon the property which lime and magnesia 
salts possess of decomposing soap (oleate and stearate of soda). The 
quantity of a solution of soap of a definite composition decomposed 
by a quantity of hard water indicates the amount of the salts present. 

DISEASES DUE TO IMPURE DRINKING=WATER. 

Hard water is popularly believed to be the cause of calculous dis- 
eases and of goitre and cretinism, but no reliable observations are on 
record showing that the belief is founded upon fact. At the same 
time it is undoubtedly true that calcareous waters produce gastric and 
intestinal derangements in those unaccustomed to their use. 

. Large amounts of suspended mineral matter are frequently pres- 
ent in river-water, and may give rise to derangements of the digestive 
organs. If there is carbonate of lime present, the water can be easily 
clarified by the addition of a small quantity of alum. Sulphate of 
lime and a bulky precipitate of hydrate of alumina are formed, which 
carry the suspended matters to the bottom. About 10 centigrammes 
of crystallized alum are sufficient to clarify a litre of water. This 
amount of alum is too small to affect the taste of the water percept- 
ibly. This method is frequently used to clarify and render fit for use 
the water of the Mississippi Eiver, which is usually very muddy. 
Lately, the city of St. Louis, which derives its water-supply from 
the Mississippi Eiver, has been using ferrous sulphate and lime as a 
coagulant, instead of alum. The action of either of these coagulants 
is to conglomerate the fine particles of clay and thus facilitate their 
sedimentation. At the same time these coagulated solid particles 
carry with them the bacteria, and a purification of 90 to 98 per cent, 
results. 



DISEASES DUE TO IMPURE DRINKING-WATER. 65 

Although the opinion is widespread that water containing much 
mineral matter, either in solution or in suspension, is deleterious to 
health, there is" very little evidence absolutely trustworthy upon this 
point. 

The presence of large quantities of organic matter in water, 
whether these matters be of animal or vegetable origin, must always 
be looked upon with suspicion. The observation was made by Hippoc- 
rates twenty-three centuries ago, that persons using water from 
marshes, i.e., water containing vegetable matter, suffer from enlarged 
spleens. Many physicians, both of ancient and modern times, seem 
to have held this opinion, but the first positive observation in medical 
literature is the now classical one of the ship Argo, reported by 
Boudin. 12 In 1834 the transport Argo, in company with two other 
vessels, carried 800 soldiers from Bona, in Algiers, to Marseilles. The 
troops were all in good health when they left Algiers. All three of 
the vessels arrived in Marseilles on the same day. In two of them 
there were 680 men, not one of whom was sick. Out of the remain- 
ing 120 men who were on the third vessel, the Argo, 13 died during 
the passage, and 98 of the 107 survivors suffered from paludal fevers 
of all forms. NTone of the crew of the Argo were sick, however. The 
two vessels exempt from sickness, and the crew of the Argo, had been 
supplied with pure water, while the soldiers on the latter vessel had 
been furnished with water from a marsh. This water was sa'id to 
have a disagreeable odor and taste. The testimony of a large number 
of East India physicians is also quoted by Parkes in support of the 
view that malarial fevers are often caused by impure drinking- 
water. The observations of Dr. Charles Smart, upon the production 
of "mountain fever" of the Western territories, have already been 
referred to. It is more than likely, however, that the cases on the 
Argo were typhoid fever. 

The causation of typhoid fever and cholera by impure drinking- 
water will be presently referred to. 

There can be very little doubt that diarrhea and dysentery are 
frequently caused by water which has been contaminated with de- 
caying organic matter. The evidence in favor of this amounts prac- 
tically to demonstration. Of course, in this as in the other instances 
cited disease is caused not by the organic matter, but by the specific 
bacteria with which the organic matter is usually associated. 



w Quoted in Parkes, op. eft., p. 48 ; Nowak, Lehrbuch der Hygiene, p. 51 
and in numerous other publications on Hygiene. 



66 TEXT-BOOK OF HYGIENE. 

It must not be forgotten that the ova of certain animai para- 
sites, such as distoma hematobium, filaria sanguinis hominis, and 
medinensis, anchylostoma duodenale, and possibly of round-worm are 
frequently present in polluted water. 

The relation of typhoid fever to the water-supply is probably the 
most important phase of the study of water from a hygienic stand- 
point. Typhoid fever is the disease most frequently caused by sew- 
age-polluted water, and next to tuberculosis and pneumonia it is the 
principal cause of sickness and death. There occur annually in the 
United States about 50,000 deaths from typhoid fever, the estimated 
number of cases being at least 500,000. The manner in which 
typhoid fever is caused by a polluted water-supply is as follows: 
The cause of typhoid fever is a bacillus discovered by Eberth and 
Koch, in 1880, and first isolated and studied in pure culture by 
Gaffky, in 1884. This bacillus is taken in with the food and drink 
which contain it, and is excreted from the body of the typhoid fever 
patient with the feces. The latter gains access to the nearest water- 
supply, and the typhoid bacilli infect the water, which becomes the 
means of conveying the bacilli to other susceptible individuals. In 
this way epidemics of typhoid fever originate in towns and cities 
which are obliged to drink the sewage of other municipalities located 
on their watershed. Of course, there is always a possibility of direct 
infection by coming in contact with the patient's feces or urine, but 
such mode of transmission, while possible in isolated cases, cannot 
result in epidemics. 

Many instances are on record where outbreaks of typhoid fever 
have been clearly attributable to pollution of the drinking-water by 
the germ of the disease from a previous case. 

One of the most remarkable of these outbreaks is that recorded 
by Dr. Thorne. 13 About the end of January, 1879, typhoid fever be- 
gan suddenly in the adjoining towns of Caterham and Eed 
Hill. Within six weeks 352 cases occurred. All other sources of the 
disease were excluded except the drinking-water, to pollution of which 
it was traced with almost absolute certainty. Caterham contained 558 
houses and Eed Hill 1700. Of the former 419 and of the latter 924 
drew their drinking-water from a common suppfy, having its source 
in a well several hundred feet deep. The insane asylum, with 2000 
inmates, and the military barracks in Caterham used water from a 
private well. There was no typhoid fever among the last two com- 



13 Report of the medical officer to the Local Government Board for 1879. 
Quoted in Fodor: Hygienische Untersuchungen, etc., II Abth., p. 261. 



DISEASES DUE TO IMPURE DRINKING-WATER. 67 

munities. During January one of the workmen engaged in some 
excavation near the public well was taken ill with diarrhea and fever, 
— probably typhoid — but was still able to continue his work. His 
dejections were often voided where they were certain to become 
mingled with the water of the common supply. This man's diarrhea 
began on January 5th and continued until the 20th of the month, 
during which time he remained at work. On the latter date he was 
compelled to quit work and take to his bed. Exactly two weeks from 
the beginning of the man's sickness, on January 19th, the first case 
of typhoid occurred in Caterham, and then rapidly increased. The 
first case occurred, therefore, just fourteen days — the incubative 
period of typhoid — after the presumed infection of the drinking- 
water by the dejections of the sick laborer, who had come from Croy- 
don, where typhoid fever was at the time prevalent. Within two 
weeks from the appearance of the first case the epidemic had reached 
its height, and then rapidly declined, disappearing almost entirely 
in a month after the outbreak. It was shown by Dr. Thorne that 
nearly all the houses in which the disease appeared were supplied 
with water from the source above mentioned, while other houses in 
the immediate vicinity of the infected ones remained free from the 
disease. 

In 1874 there was an outbreak of typhoid fever in the town of 
Over Darwen, in which nearly 10 per cent, of the inhabitants were 
attacked. Here the source of the disease was also traced to an in- 
fected water-supply. 

Dr. Buchanan has shown that an outbreak among the students 
of the University of Cambridge was likewise attributable to an in- 
fected water-supply. 

In 1885 an epidemic of typhoid fever began in Plymouth, a 
mining town of 8000 or 9000 inhabitants, situated in the Wyoming 
coal region of Penns}dvania, and on the right bank of the Susque- 
hanna Eiver. The epidemic began in April, and lasted until the 
ensuing September. There were 1104 persons attacked by the disease, 
of which number 114, or 10.3 per cent., died. The careful inspection 
made into the history of this epidemic revealed the fact that the public 
water-supply had unquestionably become polluted by the fecal dis- 
charges of a single person who was affected with the disease. This 
man had visited Philadelphia on December 25, 1884, and while there 
contracted typhoid fever. He returned to his home, on the banks 
of the stream from which Plymouth derived its water-supply, in 
January, and was ill for several weeks. During his illness the fecal 



68 TEXT-BOOK OF HYGIENE. 

discharges that wore passed during the night were thrown upon the 
snow within a lew feet of the stream. From March 21st to March 23d 
a thaw occurred, and (hiring the early days of April there were fre- 
quent warm showers. As a result, the entire mass of dejecta which 
accumulated during this man's illness was washed directly into the 
stream. About two weeks later the epidemic broke out. 

In 1895, Grand Forks, N. D., a village of about G000 population, 
had 1500 to 2000 cases (25 per cent, of her population) and about 200 
deaths. 

Previous to the epidemic the city water-supply was taken from 
the Eed Lake Eiver, which is a small, unnavigable stream. Twenty- 
four miles above Grand Forks, by car line, Crookston is situated, with 
a population at that time of about 3000. During the summer of 
1894 they had a good many cases of typhoid fever at Crookston. 
Their main sewer passed under one of the railroad embankments 
just before emptying into the Eed Lake Eiver. Some time during 
the summer the embankment crushed in the sewer, shutting it off. 
The sewage then came to the surface and formed a small stagnant 
pond held back by the embankment. This remained for about two 
months, continually increasing in amount. Just about the time that 
ice formed on the Eed Lake Eiver this sewer under the track w r as 
opened up and the dammed-back pond of sewage allowed to flow out 
rapidly underneath the ice. This was the time of year when the water 
in the river would be quite low, so that there was little chance for 
proper dilution and aeration. As a result, some two or three weeks 
after this sewage was opened, the young people of Grand Forks took 
sick by the dozens, then by the hundreds. The degree of virulency 
seemed to be unusually severe. 

In 1903, Ithaca, N. Y., the home of Cornell University, was 
stricken by a severe epidemic of typhoid fever. Of a population of 
13,000, 1350 took sick and 78 died. The cause was traced to the 
pollution of the water-supply. 

During the same year an epidemic of typhoid fever occurred in 
Butler, Pa., a city of 18,000 population, in which 1348 persons were 
stricken within the short period of ninety days and 111 deaths 
occurred, as given in the report of the State Board of Health. This 
town was supplied with water from a stream more or less polluted, but 
just prior to the epidemic the private water company installed a me- 
chanical filter which was doing satisfactory work until October, when, 
on account of the changes in the pumping station, the filter was shut 



DISEASES DUE TO IMPURE DRINKING-WATER. 69 

off at intervals to allow work to proceed on these changes ; and imme- 
diately there appeared the epidemic. 

AYithin ten days after the polluted water began to be pumped 
direct the physicians were overwhelmed with calls. By November 
29th the disease was so widespread and serious that a public mass 
meeting was called and a relief committee organized. In order to 
meet the expense of the committee $25,000 was voluntarily sub- 
scribed and it was estimated that $75,000 would be needed. Nurses 
and physicians were procured from Pittsburg, Philadelphia, and other 
places. The work at the station was rushed to completion at the 
earliest possible moment, but to December 17, 1903, there was a total 
of 1270 cases reported, with 56 deaths. 

In this case the infection was traced to the drainage from a 
miner's cabin in which there was typhoid fever. The drainage from 
this cabin was directly into a small branch, the flow from which en- 
tered into the stream from which the supply was taken, at a point 
a few yards above the intake to station. 

In 1904 an epidemic of typhoid fever occurred in Columbus, 
Ohio, with a population of 140,000. The number of cases was 
1640, number of deaths 166. The source of the epidemic was traced 
to the pollution of the Scioto River with the sewage from the State 
Hospital. 

Quite recently a severe epidemic of typhoid fever occurred in 
Scranton, Pa. This epidemic was investigated by Dr. Eobin and the 
following are excerpts from his report: — 

"A visit to the Bureau of Health showed at a glance the serious- 
ness of the conditions as well as the determined effort on the part 
of the officials to meet them successfully. Every desk in the office 
had behind it a busy worker. Dr. Keller, the superintendent, was 
busily engaged receiving reports and giving orders. Every few min- 
utes a messenger, police officer, or inspector came in with a report 
and for instructions. Physicians came in for information, and the 
telephones were in constant use. The whole aspect reminded one 
of army headquarters during an important battle. 

"On December 3, 1906, 5 cases of t3 r phoid fever were reported 
to the Bureau of Health. From that date to December 12th, 20 cases 
were reported. There is every reason to suppose that typhoid cases 
occurred prior to that date, and in larger numbers than were reported, 
the attending physicians having diagnosed them as grippe. On De- 
cember 12, 24 cases were reported, and from that date up to January 



70 TEXTBOOK OF HYGIENE. 

5, 1907, the number of cases reported reached 970, with 77 deaths 
attributed. o\' which 55 wore officially reported. 

"The cases of typhoid lever are practically confined to the central 
part of the city and West Scranton, which were supplied w r ith high 
service from the Elmhurst Eeservoir. The disease does not appear 
to be confined to any particular class of people, the rich and poor 
suffering alike, nor is there any relation of the epidemic to the sani- 
tary conditions of certain sections of the city. While the poor suffer 
most on account of a lack of means, and their sufferings are more in 
evidence, the well-to-do and the rich contribute their full quota to the 
morbidity and mortality list. The deaths of many prominent men 
and women have already been chronicled, and many a happy home 
has been shattered by this dread disease. 

"The consensus of opinion of all the officials, local as well as State, 
with the exception of the Scranton Gas and Water Company, is that 
the water supply is to blame for the epidemic. The city of Scranton, 
with a population of about 120,000, is supplied with water obtained 
from mountain streams. These are intercepted by four small stor- 
age reservoirs of about 1,000,000 gallons each, and merge into what 
is known as Eoaring Brook. The latter empties into the Elmhurst 
Storage Eeservoir of a capacity of 1,600,000,000 gallons, and from 
this, overflowing a dam, passes through a pipe to ~Ro. 7 reservoir, 
from w r hich the city is ordinarily supplied. A pipe-line also passes 
from the Elmhurst reservoir to Lake Scranton, a storage reservoir of 
2,000,000,000 gallons capacity. When the flow over the dam at the 
Elmhurst Eeservoir is insufficient to supply the city, the supply is 
augmented by drawing on Lake Scranton. The watershed is sparsely 
populated and there are no large centres of pollution, the only village 
of any size being Moscow, with a population of about 900, which 
drains directly into the Eoaring Brook. However, two railroad lines 
pass along the branches of the Eoaring Brook, the Erie and 
D., L. & W., and these form a possible source of pollution. 

"The water-works are owned by the Scranton Gas and Water Com- 
pany and are estimated by the owners to be worth $12,000,000. 

"The water has been of good quality and there is no record of any 
marked pollution of the supply, nor would the mortality of typhoid 
fever in the past indicate that the supply was not comparatively pure. 
In the report of the Bureau of Health for 1905, the following state- 
ment is made : — 

" The city of Scranton can proudly boast of its pure and unlimited 
water supply, as al?o the protection given to its water-sheds. The bac- 



DISEASES DUE TO IMPURE DRINKING-WATER. 71 

teriologist, Dr. Wilson, has, on numerous occasions, examined speci- 
mens from the different reservoirs at different times, and found them 
in excellent condition/ This statement seems to find corroboration 
in the low typhoid fever mortality, the deaths from typhoid fever 
being in 1905-1906, 11 and 25 respectively. 

"However, amidst all this security and confidence, the blow 
struck. Whether the sudden contamination of the water-supply 
came from passengers suffering or convalescent from a mild form of 
typhoid fever, on. either, or both of the railroads; whether it came 
from one or more of the hunters who have hunted on the water-shed ; 
whether from some visitor at the hotel at Moscow, which drains into 
the Eoaring Brook, is not known. The fact, however, is that the sup- 
ply in the Elmhurst Reservoir was found badly polluted, and what 
is of the greatest importance, the typhoid bacilli have been actually 
discovered in some of the samples of water analyzed at the State 
Laboratories at Harrisburg. This, I believe, is the first instance in 
■ this country of actually demonstrating the presence of typhoid bacilli 
in water suspected of causing typhoid fever. In view of this fact, 
I made special inquiries, and was assured by Dr. Johnson and Mr. 
Snow that the bacillus which the State bacteriologist isolated from the 
water, responded to all the cultural and other tests, and was found 
identical with the typhoid bacillus isolated from the discharges from 
typhoid patients at Scranton. This remarkable and unique demon- 
stration establishes beyond doubt not only the cause of the Scranton 
epidemic, but the relation of water-supplies to typhoid epidemics in 
general. 

"As a result of these findings the supply from Elmhurst Reservoir 
has been cut off and the city of Scranton is supplied from Lake Scran- 
ton. As a further precaution, the health authorities have urged the 
people to boil the water and milk, a precaution which is generally 
being observed. 

"It should be noted that the health authorities have shown re- 
markable ability and zeal in coping with the serious situation. Daily 
bulletins apprise the people of the exact situation, while thorough 
disinfection of the premises is rigorously enforced. The hospitals 
and charitable institutions have lent their entire forces to meet the 
conditions prevailing at the present time, while the press has all 
along supported and helped the administration. As a result there is 
no panic. The situation is viewed calmly and sensibly, and there is 
every reason to believe that the epidemic will soon be under control. 
"The Scranton epidemic still further emphasizes the fact, long 



TEXTBOOK OF HYGIENE. 



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76 TEXT-BOOK OF HYGIENE. 

ago recognized in Europe, that no surface water is safe without final 
purification, and that an ounce of prevention is worth many pounds 
of euro." 

The above-cited epidemics emphasize the danger confronting 
every municipality in this country that depends on a surface water 
for its supply. In fact, Pittsburg and Allegheny, and Philadelphia, 
are subjected to annual typhoid epidemics which, in point of destruc- 
tion of human lives, exceed any other agency of death. For the last 
14 years there have been reported in Pittsburg some 30,000 cases and 
over 4200 deaths. 

The relation of typhoid fever to the water-supply of the large 
American cities is best shown in the table on pages 72 to 75. 

On the other hand, Hague, Berlin, Eotterdam, Breslau, Ham- 
burg, Zurich, Amsterdam, London, Edinburgh, and Warsaw, European 
cities supplied with water filtered through slow sand filters, have an 
average typhoid mortality of 8.3 per 100,000. 

As it is with typhoid fever, so also with cholera. In the instance 
to be presently noted the connection between the infected water, on 
one hand, and the outbreak of cholera, on the other, is so clearly 
shown as to be almost equivalent to a mathematical demonstration. 
The facts in the case were brought to light after a patient inquiry by a 
commission, whose report drawn up by Mr. John Marshall has made 
the occurrence classical. In 1854 the people of a well-to-do and other- 
wise healthy district in the eastern part of London suffered severely 
from cholera. LTpon inquiry the fact was elicited that a child had 
died of cholera at No. 40 Broad Street, and that its excreta had been 
emptied into a cess-pool situated only three feet from the well of a 
public pump in that street, from which most of the neighboring 
people took their drinking-water. It was further discovered that the 
bricks of the cess-pool wall were loose and permitted its contents to 
drain info the pump-well. (It shouM be noted that the communica- 
tion between the cess-pool and the well was direct; that there was 
immediate drainage, not percolation through the soil.) In one day 
140 to 150 people were attacked, and it was found that nearly all the 
persons who had the malady during the first few days of the outbreak 
drank the water from the pump. When the pump was closed to public 
use by the authorities the epidemic subsided. The most singular case 
connecter! with this outbreak was the following: In West End. 
Hampstead, several miles away from Broad Street, there occurred 
a fatal case of cholera in a woman 59 years old. This woman formerly 
lived in Broad Street, but had not been there for many months. A 



STORAGE AND PURIFICATION OF WATER. 77 

cart, however, went daily from Broad Street to West End, carrying, 
among other things, a large bottle of water from the pump referred to. 
The old lady preferred this water to all others, and secured a daily 
supply in the manner stated. A niece, who was on a visit to the old 
lady, drank of the same water. She returned to her home, in a high 
and healthy part of Islington, was likewise attacked by cholera and 
died. There were, at this time, no other cases of cholera at West End, 
nor in the neighborhood of these last two persons attacked. 

Most of the. English medical officers in India hold strongly to the 
view that cholera is spread by polluted drinking-water, and the evi- 
dence in its favor is very strong. 

In 1885 Dr. Eobert Koch discovered the cholera spirillum in a 
water-tank in Calcutta, used as a source of domestic suppty, and in 
this way furnished another link in the chain of evidence connecting 
the spirillum, the drinking-water, and the outbreak of the disease. 

The evidence in favor of the influence of impure drinking-water 
on the causation of other diseases than those mentioned is not suffi- 
cient to justify any conclusions at present. 

The source of a water-supply may be pure, yet pollution may 
occur before the water is used by persons to whom it is distributed. 
Supply-pipes may become defective, and the water become contamin- 
ated with sewage or other deleterious substances. 

Aside from the practical question of the causation of disease by 
polluted water, a more abstract and esthetic idea is involved in con- 
sciously taking any impurity into the system. The instincts of man, 
as well as of most animals, revolt at it. These inborn instincts, which 
constitute the sanitary conscience, as Soyka says, demand purity of 
food and water, as they insist on cleanliness of the body, of clothing, 
and of the dwelling. 



STORAGE AND PURIFICATION OF WATER. 

Wherever a large supply of water is needed, unless drawn direct 
from a well or spring, or pumped directly from its source, arrange- 
ments for storage are necessary. Cisterns and large reservoirs are 
made use of for this purpose. River-water, especially, requires a 
period of rest, in a storage reservoir, in order to allow deposition of the 
large amount of suspended matter in it. Prolonged storage also gives 
opportunity for the conversion of possibly deleterious organic com- 
pounds into simple and perhaps harmless combinations. Usually, in 
an elaborate system of water-works, a series of reservoirs is built, in 



7S TEXT-BOOK OF HYGIENE. 

which the water is stored successively, so that before its final distribu- 
tion through the street-mains it has become quite clear and pure. 
Filtration on a large scale is also used in connection with storage 
reservoirs in order to secure greater purity of the water. 

In the distribution of water, care should be taken that nothing 
deleterious is taken up by the water in its passage through the pipes. 
Lead-poisoning is not infrequent from drinking-water that has passed 
through a long reach of lead pipe, or which has been standing in a 
vessel lined with lead. Tanks and storage systems should therefore 
not be lined with lead, and the use of lead pipe in the supply service 
should be avoided as much as possible. Fortunately, most natural 
waters possess a considerable portion of carbon dioxide, which forms 
with the lead an almost insoluble carbonate of lead. This carbonate 
of lead is deposited on the inside of the pipes, and protects both the 
pipes against erosive action from other constituents of the water, and 
also prevents the contamination of the water by the lead. An excess 
of carbon dioxide in the water renders this deposit soluble, and may 
cause serious poisoning. Any water which is shown by analysis to 
contain over 1 milligramme of lead per 100,000 is dangerous and 
should be rejected. 

Owing to the possibility of defilement of the water from improper 
construction of hydrants, all outdoor hydrants should be discouraged 
as much as possible, and should be replaced by a simple tap-cock 
indoors. The pipes should also be laid deep enough under-ground, 
or otherwise protected against freezing in winter. 

A number of methods, all more or less efficient, have been intro- 
duced to purify water when it needs purification before being fit for 
use. These methods either comprise filtration or seek to purify the 
water without the aid of this process. One of the methods of puri- 
fication without filtration consists in exposing the water to the air 
in small streams. This was proposed by Lind, more than a century 
ago, and has since been frequently revived. The water is passed 
through a sieve, or a perforated tin or wooden plate, so as to cause 
it to fall for a distance through the air in finely-divided currents. 
By this process sulphuretted hydrogen, offensive organic vapors, and 
possibly dissolved organic matters are removed. This process has 
been used in Eussia on a large scale. 

By boiling and agitation, carbonate of lime, sulphuretted hydro- 
gen, and organic matter are removed or rendered innocuous. Vege- 
table germs are usually destroyed, although Tyndall has shown that 
some bacterial germs withstand a temperature higher than that of 



STORAGE AND PURIFICATION OF WATER. 79 

boiling water. Pathogenic germs are, however, all destroyed by boil- 
ing water acting on them for ten minutes, as shown by Dr. G. M. 
Sternberg. 14 

As has already been mentioned, 15 alum is one of the readiest and 
most efficient means of removing suspended matters from water. 
However, it should not be used in large quantities. 

Permanganate of potassium is sometimes used to purify water 
containing considerable organic matter. The permanganate rapidly 
oxidizes the organic matter, and is believed to render it harmless. 
There is no certainty, however, that the germs of specific diseases are 
destroyed by the action of this salt, in the proportion in which it 
could be used for the purposes of water purification. 

A yellow tint is given to the water by the permanganate, which is 
due to finely-divided peroxide of manganese. This does no harm, 
but is unpleasant. Bromine has been used for a similar purpose, and 
is claimed to give very good results. The bromine may be neutralized 
by ammonium or other alkali. 

In 1904, Moore and Kellerman, 16 of the Bureau of Plant Indus- 
try, United States Department of Agriculture, advocated the use of 
copper sulphate, first for the destruction of algae, and later for the 
purification of water. They found that in proportion of 1 : 100,000 
copper sulphate is an efficient germicide, destroying the colon and 
typhoid bacilli. It was also discovered that copper vessels are capable 
of purifying water through action of the colloidal copper which is 
taken up by the contents. For a time these claims received enthusi- 
astic endorsement from many quarters, and it seemed as though the 
difficult problem of water-purification in a ready manner had been 
satisfactorily solved. However, the enthusiasm cooled down consider- 
ably when reports began to appear from various laboratories, show- 
ing that the claims of Kellerman and his followers are greatly over- 
drawn. Aside from the fact that it would not be safe to introduce 
copper sulphate into the system, even in minute and theoretically 
harmless quantities, for a long time, the fact has been brought out 
that the germicidal action of copper is very uncertain. Among the 
bacteriologists who reported adversely to this new method, Clark 
and Gage, of the Lawrence Experiment Station, have furnished the 
most damaging evidence. In an article on the bactericidal action 
of copper 17 the authors very properly emphasize that "the weak point 

"Report of Committee on Disinfectants, 1888. 
X5 See page 64. 

16 U. S. Dep't Agriculture. Bur. Plant Ind., Bull. No. 64. 
* "The Jour, of Inf. Diseases, Supplement No. 2, Feb., 1906. 



SO TEXT-BOOK OF HYGIENE. 

in the conclusions of Moore and Kellerman with regard to the de- 
struction of typhoid by copper is that they were drawn from analy- 
ses in which the largest amount of water tested was 1 c. c, and the 
usual amount tested was less than .01 c. c, It is generally conceded, 
especially when dealing with laboratory cultures, that the great ma- 
jority of the typhoid bacilli are quickly destroyed by conditions un- 
favorable to their growth. It has also been repeatedly shown that a 
few germs are much more resistant than the majority, and may sur- 
vive even under the most unfavorable conditions for many days. All 
epidemiological evidence points to the conclusion that the germs which 
are able to live under unfavorable conditions are also extremely patho- 
genic, and that, while it may help to destroy the majority of the 
bacilli, no method of sterilizing water is thoroughly effective unless 
it will accomplish the destruction of the especially resistant indi- 
viduals. 

"It is unsafe to conclude that because a certain species of bac- 
teria, especially a pathogen like B. typhosus, is not found in a loopful 
of the water, or even in 1 c. c, that there is jlo danger from the use 
of that water. The average drinking-glass holds about 300 c. c, and 
until repeated tests of volumes as large as 100 c. c. have been made 
and the germ proved to be absent, the water under observation can- 
not safely be said to be free from the test forms." 

The authors have used large quantities of water in their experi- 
ments and have varied the experiments to cover the ground thor- 
oughly. Their conclusions are : — 

"The treatment of water with copper sulphate or by storing it in 
copper vessels has little practical value, for the following reasons: — 

"1. The use of any method of sterilization which is not absolutely 
effective is dangerous in the hands of the general user, tending to 
induce a feeling of false security, and leading to the neglect of or- 
dinary precautions which, would otherwise be employed. 

"2. The removal of bacteria, B. coli and B. typhosus, by allowing 
a water to stand in copper vessels for short periods, while occasionally 
effective, is not sure, and the time necessary to accomplish complete 
sterilization is so long that the method would be of no practical value 
to the ordinary user. Furthermore, metallic copper seems to have 
little more germicidal power than iron, tin, zinc, or aluminum. 

"3. Although the removal of B. coli and B. typhosus is occasion- 
ally accomplished by dilute solutions of copper sulphate, these organ- 
isms may both live for many weeks in water containing copper sul- 
phate in greater dilutions than 1 : 100,000; and in order to be safe 



STORAGE AND PURIFICATION OF WATER. 81 

dilutions of 1 : 1000 must be used, in which case the water becomes 
repugnant to the user because of its strongly astringent taste. 

"4. In some instances very dilute solutions of copper sulphate or 
colloidal copper absorbed from contact with clean metallic copper, 
appear to have a decidedly invigorating effect on bacterial activity, 
causing rapid multiplication, when the reverse would have been true 
had the water been allowed to stand the same length of time without 
any treatment." 

Eegarding the effect of copper and other metals on B. coli, the 
authors found that the organism disappears under the action of the 
respective metals in the following number of days: zinc, 10 days; 
iron, 15 days; tin, 41 days; aluminum, 41 days; copper, 43 days; 
lead, 97 days; and in another experiment: zinc, 10 days; copper, 
10 days; tin, 23 days; iron, 23 days; lead, 23 days; aluminum, 
31 days. 

Filtration. — The purification of water by filtration has been 
shown to be the most reliable means of removing both suspended mat- 
ter and bacteria from polluted water. Filtration is practiced on a 
small scale — domestic filters — and on a large scale. Of the domestic 
filters only those made of unglazed porcelain (the Pasteur filters) 
or infusorial earth (the Berkefeld filter) are to be relied upon. 
These niters are made of a porous material, the pores forming tortu- 
ous channels in which the bacteria lodge and are retained. After 
a time the filter becomes permeated with bacteria and the latter are 
pushed through, as it were, by the incoming armies. To make them 
yield a satisfactory effluent, the filtering unit should be frequently 
scrubbed and sterilized in the oven or by boiling at least once a month. 
Maignen's domestic filter, made of granulated charcoal and asbestos, 
is said to be quite satisfactory. All other domestic filters on the 
market, and their name is legion, are practically worthless, if not 
actually harmful because of the false security which they give. 

On a large scale, water may be purified by sedimentation, slow 
sand-filtration, or the English method, rapid sand-filtration, or the 
American method, which is also known as mechanical filtration. 

In the process of sedimentation the water is confined in one or 
more large reservoirs holding 30,000,000 to 50,000,000 gallons and 
allowed to become clarified by the particles of mud falling to the bot- 
tom. Incidentally, the bacteria are carried down and some oxidation 
of the organic matter takes place. Usually about 75 per cent, of 
purification takes place by this method. In St. Louis the water is 
treated with iron sulphate and lime before final sedimentation. By 



82 



TEXT-BOOK OF HYGIENE. 




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STORAGE AND PURIFICATION OP WATER. 



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Fig. 5. — Plans of Intake and Water-tower Used in Connection with 
the Reservoir. 



84 TEXT-BOOK o\? EYGIENB. 

this method the effect o( sedimentation is greatly enhanced and the 
purification o\' the water is much greater. 

Slow Sand FILTRATION. — This method was originally employed 
by the London water companies as a means of removing from the 
water the matter in suspension. Later, however, Frankland ha> shown 
that the sand-filters also remove the bacteria or most of them, and 
thus purify as well as clarify the water. Since 1890 the Massachu- 
setts State Board of Health has been conducting extensive experi- 
ments on slow snnd-filtration, and it is these experiments that have 
elucidated the subject of filtration and placed it on a solid scientific 
basis. The principle underlying slow sand-filtration is a biologic one. 

The forces wdiich bring about purification of the water in the 
sand-filter are exactly the same as operate under natural conditions 
when a foul surface pool percolates slowly through the ground and 
crops out in the form of a pure, sparkling spring. The upper layers 
of the ground swarm with various bacteria which live on dead organic 
matter, so-called saprophytes. Among them are certain species which 
convert the nitrogenous substances into ammonia; others convert the 
ammonia into nitrites and nitrates, the so-called nitrifying bacteria; 
again others break up cellulose; in a word, the organic substances 
of the water are attacked from all sides and converted into harmless 
mineral substances, the latter to be taken up by the plants as food. 
If any pathogenic bacteria happen to be present they find a strange 
and altogether uncongenial environment. In the first place, they are 
accustomed to body-heat, and the comparatively low temperature chills 
them ; then, they are parasitic in nature and cannot prepare food for 
themselves, wdiile the food that they find is rapidly consumed by 
their competitors, which are in greatly predominating numbers. 
Thus, the pathogens soon perish and are rapidly consumed by the 
saprophytes. That this is not a fanciful representation may be 
demonstrated by laboratory experiments, which will show, for in- 
stance, that anthrax bacilli are rapidly destroyed in putrefying blood ; 
that typhoid bacilli soon disappear in feces; that any of the patho- 
genic bacteria are quickly crowded out in cultures wmich contain also 
saprophytic bacteria. 

Conditions very much similar to those existing in nature prevail 
in the slow sand-filter. Here we have a bed of fine sand about three 
feet thick, through which the water percolates at a rate of 3,000,000 
to 4,000,000 gallons per acre per day. While the water passes through 
the sand, the suspended matter is strained out and is deposited be- 
tween the sand-grains, in the upper inch or two. The infusoria, algae, 



STORAGE AND PURIFICATION OF WATER. 



85 



and bacteria in the water become entangled in what is now a very 
fine sieve and form a slimy film about the sand-grains, on the surface 
of the bed. No sooner are the various bacteria domiciled than they 
at once commence to work, each species performing its particular 
function and making a struggle for existence. The surface film of 
the sand-bed, or what the Germans call "schniutzdecke" (mud-film), 
is now teeming with life and is the field of energetic biologic activity, 
the result of which is the transformation of the complex organic 
molecules into simple inorganic compounds. Any pathogenic bacteria 
that may be present in the water become enmeshed in this film and 
soon perish in the unfavorable environment. In time the upper mud- 




Fig. 6. — Plans of Slow Sand Filters. These consist of concrete 
basins, on the floor of which are laid tile or terra cotta underdrains; 
over these, from three to six inches of gravel in successive layers, 
beginning with the very large sizes at the bottom and the finest at 
the top; over this about three feet of fine sand, and over this three 
to four feet of water. 



film becomes more and more compact, until only a comparatively 
small amount of water passes through. This happens, under ordinary 
circumstances, about once in three weeks. When this occurs, the filter 
is drained, the upper inch of sand removed by means of shovels, and 
filtration resumed. 

The greatest impetus to filtration and the most remarkable 
demonstration of its efficiency in preventing water-borne diseases were 
furnished by the epidemic of cholera which visited Hamburg in 1892. 
The cities of Hamburg and Altona are separated by an imaginary line, 
so that nothing in their surroundings or in the nature of their popula- 
tion distinguished one from the other. Both cities depend for their 



g6 TEXT-BOOK OF HYGIENE. 

water-supply on the polluted river Elbe, with this difference, that 
while the intake for Hamburg is situated above the city, that for 
Altona is situated below Hamburg, i.e., the water-supply of Altona 
receives additional pollution of some 800,000 inhabitants. When 
the epidemic broke out Hamburg suffered a loss of 1250 lives per 
100,000, while the number of deaths in Altona was only 221. So 
clearly denned was the path pursued by the epidemic that in one 
street which marks the division between these towns, the Hamburg 
side was stricken down with cholera, whilst that belonging to Altona 
remained free. It was found that in the houses supplied with the 
Hamburg water cholera was prevalent, whilst those furnished with 
Altona water remained free from the disease. Xow, the reason for 
this difference was in the fact that Altona filtered the water, while 
Hamburg did not. Fate, moreover, furnished additional proof of this 
fact. During the ensuing winter, when the epidemic of cholera had 
almost died out in Hamburg, an outbreak of the disease occurred 
in Altona. A searching inquiry was instituted and it was found that 
instead of the usual small number of bacteria in the effluent from 
the filters, about 50, the number rose to 1000 and more in a c. c. The 
cause for this inefficiency was soon discovered. It was found that 
one of the sand-filters, which had been cleaned during the frost, had 
become frozen over, and was consequently not able to retain the bac- 
teria. But imperfect as the filters then were, they nevertheless saved 
the city from another severe epidemic, as shown by the limited num- 
ber of cases. 

As a result of his studies of the Altona filters, E. Koch arrived 
at the following conclusions: — 

1. The real effective agent in removing micro-organisms from the 
water is the layer of slimy organic matter which forms upon the sur- 
face of the sand. 

2. If this surface be removed by scraping, or its continuity af- 
fected in any way, as by freezing of the surface, the number of bac- 
teria which pass through the filter increases considerably; in fact, 
both cholera and typhoid germs may pass in sufficient numbers to 
cause an epidemic amongst those who use the imperfectly filtered 
water. 

3. Filtration should not exceed a rate of 2,000,000 gallons per acre. 

4. After a filter-bed has been scraped, water should be allowed 
to stand upon it for at least 24 hours to allow of the slime depositing 
before filtration is commenced and the water which first passes should 
be wasted. 



STORAGE AND PURIFICATION OF WATER. 87 

5. Each separate filter-bed must, when in use, be investigated 
bacteriologically once each day. 

6. Filtered water containing more than 100 bacteria per cubic 
centimetre should not be allowed to reach the pure-water reservoir. 

Perhaps no single investigation has contributed as much towards 
our knowledge of the underlying principles of filtration as the experi- 
ments performed at the laboratories of the Massachusetts State Board 
of Health since 1890. 

The more important results of these experiments may be sum- 
marized as follows: — 

1. The depth of sand, within certain limits, exerts but little 
influence on the efficiency of a sand filter, except when the rate of fil- 
tration is high; with moderate rapidity of filtration (2,000,000 gal- 
lons per acre daily) one foot of sand is as effective as five feet. 

2. The effect of scraping the sand to remove the clogged surface 
is to cause an increased number of bacteria to pass through the filter. 
Usually the filter requires three days' use after scraping to reach a 
maximum degree of efficiency. The effect of scraping is more marked 
in shallow than in deep filters, and with high rates than with low rates 
of filtration. 

3. Over 80 per cent, of the bacteria removed are found in the 
upper inch of sand, and 55 per cent, in the upper quarter-inch. The 
B. prodigiosus, which is very like the typhoid bacillus in its mode 
of life in water, was not found below the upper inch. 

4. The average depth of sand necessary to be scraped from the 
surface of the filter was V 4 inch, but was found to vary with the 
size of the sand, decreasing as the fineness of the sand increased. 

5. Much less water will pass a filter at 32° F. than 70° F., 
owing to the increased viscosity of the water. 

6. Within certain limits and under equal conditions the quantity 
of water passed between successive scrapings is not influenced by the 
rate of filtration. 

7. Finer sands require more frequent scrapings than coarser 
sands. 

8. Shallow filters require more frequent scrapings than deeper 
ones. " 

9. During the summer months the temperature and other con- 
ditions for continuation of life of bacteria at the surface of filters 
are more favorable than at any other time. 

Experiments performed at Wilmington, Del., by Dr. A. Eobin, 
indicate that excellent efficiency may be obtained at a rate of 4,000,- 



gg TEXT-BOOK OF HYGIENE. 

000 gallons per acre per day, if the raw water is passed, previous to 
iiltration, through a preliminary filter, which removes about 50 to 
75 per cent, of the turbidity and bacteria. 

Following the remarkable demonstration of the efficiency of slow 
sand-filtration in removing cholera bacilli from the water, sand-filters 
were installed in almost all the large cities of Europe, and wherever 
installed have reduced typhoid mortality to a very small percentage. 

In this country, the first slow sand-filter was built by Kirk- 
wood, in Poughkeepsie, N. Y., in 1877. This filter, however, was 
operated without any particular regard to the scientific aspect of fil- 
tration, and under disadvantageous climatic conditions. 

The first filter which has contributed very largely to our know- 
ledge of the subject, and which has served as a model for other plants, 
is the slow sand-filter constructed in Lawrence, Mass., in 1893. This 
filter has been in operation ever since, giving excellent results both 
as to the improvement of the polluted Merrimac water and the reduc- 
tion of the typhoid mortality in the city. This is shown in the fol- 
lowing table : — 





Table 


XI. 






Death Rate Pe 


r 100,000. 




Year. 


Before Filtration. 


Year. 


After Filtration. 


1885 


42.0 


1893 


86.6 


1886 


57.5 


1894 


50.0 


1887 


. 117.5 


1895 


18.6 


1888 


120.0 


1896 


16.2 


1889 


137.5 


1897 


13.9 


1890 


133.3 


1898 


33.0 


1891 


122.0 


1899 


18.1 


1892 


111.1 


1900 


18.0 



Following the introduction of slow sand-filtration in Lawrence, 
slow sand-filters have been constructed in a number of American 
cities, the most notable of which is Albany, N. Y. In the latter city 
a covered slow sand-filter was constructed by Mr. Hazen in 1899. 
The improvement in the mortality from typhoid fever and diarrheal 
diseases has been very marked, as shown by Mr. Bailey, the superin- 
tendent, in his report for the year ending 1901 : — 

"An examination of the health records of the city shows some 
interesting features coincident with the commencement and continued 
operation of the filter, as follows : — 



STORAGE AND PURIFICATION OF WATER. 



89 



Table XII. 

Death Record. 

General Diarrheal . Typhoid 

Av. Av. Av. 

previous previous previous 

10 10 10 

yrs. 1899 1900 yrs. 1899 1900 yrs. 1899 1900 

October 153 138 144 5 2 5 4 4 5 

November .... 162 138 135 3 1 5 4 

December 194 148 133 6 1 7 1 

1900 1901 1900 1901 1900 1901 

January : 235 135 188 6 1 2 11 3 2 

February 197 146 157 6 2 11 1 3 

March 215 180 164 5 5 1 12 3 1 

April 197 202 156 4 ' 1 9 5 1 

May 173 152 139 3 1 4 4 1 

June 159 112 145 10 7 1 4 1 3 

July 191 162 142 39 27 11 4 3 

August 162 116 134 21 16 14 7 6 3 

September .... 148 125 139 i2 5 12 6 4 4 

Total ...2186 1754 1776 120 67 48 84 35 27 
Reductions, per cent... 19.77 18.76 44.17 60.00 58.33 67.86 

"There has been no general sanitary improvement in the city in 
this time other than the improvement of the water due to filtering. 
These figures show facts, and should be susceptible to accurate inter- 




tiORjF Filters , JVajhinvton. ELJL 



Fig. 7. — Showing Interior of Filter Recently Constructed in 
Washington, D. C. 



90 



TEXT-BOOK OF HYGIENE. 



pretation. My inference from them is, that, as a result of the pure 
water now being supplied, there is a better general condition of 
health, as shown by a decided reduction in diseases caused by filth 
and disease-germs that arc* water-borne." 

The Albany filter has continued to give excellent results from a 
sanitary standpoint. Slow sand-filters have been constructed in Prov- 
idence, E. I., Washington, D. C, Hudson, N". Y., Mount Vernon, 
X. Y., Far Rockaway, L. I., Ilion, N. Y., Yonkers, N. Y., Somers- 
worth, N. H., Ashland, Wis., Superior, Wis., St. Johnsbury, Vt., 
Milford, Mass., Nantucket, Mass., Nyack, N". Y., Lambertville, ~N. J., 
Salem, N. J., Eock Island, 111., Grand Forks, N". D. ; and are in the 
course of construction in Philadelphia, Pa., Pittsburg, Pa., and Wil- 
mington, Del. 

Our experience thus far gained from the results of filtration 
enables us to make the general proposition that properly filtered water 
is fully equal in its hygienic purity to a pure supply from natural 
sources. This is shown by Hazen in the following table: — 



Table XIII. 

Deaths from Typhoid Fever per 100,000 per Annum. 



Place 



Zurich, Switzerland Filtration. 

Hamburg, Germany Filtration. 

Lawrence, Ma«s Filtration. 

Albany, N. Y Filtration 

Lowell, Mass., Kiver water to ground 

water 

Newark, N. J., Eiver water to upland 

water 

Jersey City, N. J., River water to 

upland water 



Averages . 



1885 
1892-93 
1893 
1899 

1895-96 

1892 

1896 



go 

£ © 
© O 

.!-, © 
few 



76 

47 

121 

104 

97 

70 

77 



85 



6C 

© v 



10 

7 
25 

28* 

21 
16 
24 



19 



a, © 
Pntf 



87 
85 
79 
73 

78 

77 

69 



78 



*Four years. 



Mechanical Filters. — In the mechanical, rapid or American 
system of filtration, the water is conducted through sand in about the 
same manner as in slow sand-filters. In a mechanical filter the action 
is both mechanical and chemical, the foreign substances in the water 



STORAGE AND PURIFICATION OF WATER. 91 

being retained in the sand mechanically, while their retention is 
aided by the application of chemicals. There 4s no biological 
activity in a mechanical filter as there is in the slow sand-process. 
By reason of the assistance of the chemicals, and by virtue of the 
absence of the biological activity on a mechanical filter, it can be 
operated at much higher rates than slow sand or biological" filters as 
they may be called. The usual rate at which mechanical niters are 
operated is 125,000,000 gallons per acre per day, while slow sand- 
filters are operated at about the rate of 3,000,000 gallons per acre per 
day. A more rapid passage of the water through a slow sand-filter 
would be liable to wash the bacteria from the sand-grains about which 
they live, and so interfere with the successful operation of the filter. 

The chemicals usually used in mechanical filters are sulphate 
of aluminum or sulphate of iron and lime. The way these chemicals 
act is as follows : When sulphate of aluminum is used, it is led into 
the supply somewhere before the water enters the filters and there 
combines with the lime naturally present in nearly all waters to form 
hydrate of aluminum and sulphate of calcium. The sulphate of cal- 
cium remains in solution in the water, but the hydrate of aluminum, 
being insoluble, agglomerates, by means of its stickiness, the bacteria 
and other particles in suspension in the water, into masses of such 
size that they cannot pass between the sand-grains as they would if 
they had not been massed together by the action of the chemicals. 
When sulphate of iron and lime are used, the action is exactly similar, 
only instead of having hydrate of aluminum we have hydrate of iron. 
Having all the foreign particles in the water agglomerated in one of 
these ways, they are much more easily retained by the sand than in 
the slow sand process, consequently the filter can be operated at a 
more rapid rate. Being operated at a more rapid rate, the dirt accu- 
mulates on the surface of the sand faster than it does in a slow sand 
plant, with the consequent necessity of more frequent cleaning. 

In mechanical plants the cleansing of the sand is accomplished 
by turning a current of filtered water upward through the sand, and 
at the same time agitating the whole bed of sand by means of rakes 
driven mechanically or by compressed air forced through the sand 
from below. By either means of agitation the sand-grains are forced 
rapidly against each other and all foreign matter is forcibly removed 
from their surfaces, and carried by the current of water to the top 
of the filter, whence it is conducted to the sewer by pipes arranged 
for that purpose. The operation of cleaning a mechanical filter usu- 
ally takes about ten minutes, and the frequency with which it has 



92 TEXT-BOOK OF BYGIENE. 

to be performed depends entirely upon the character of the water 
treated. Ordinarily a filter has to be cleaned about even- twenty- 
lour hours, and it requires from 2 per cent, to 5 per cent, of the fil- 
tered water for cleaning purposes. 

Regarding the efficiency of mechanical filters, it may be said that, 
when carefully constructed and skillfully operated, they give hy- 
gienic efficiency equal to that of a slow sand-filter; but, on the other 
hand, the mechanism of operation is much more complex, the possi- 
bility of some unlooked-for derangement greater, with consequent lia- 
bility to get out of order and thus result in imperfect purification 
of the water. 

The comparative utility of slow sand and mechanical filters was 
summarized by Col. A. M. Miller, John W. Hill, and Kudolph Her- 
ring, acting as a commission of experts for Pittsburg, Pa. The fol- 
lowing is an extract from their report, and the conclusions deduced : — 

"It was found by the experimental work carried on by the former 
commission, for Pittsburg conditions, that as to first cost mechanical 
filtration was the cheaper process. Upon reviewing the subject at the 
present time, we are of the same opinion, but would add that the ex- 
pense of operation being greater for the mechanical filters, the total 
expense of the two methods becomes nearly equal, and the preference 
should depend on other than financial considerations. 

"As to efficiency in removing bacteria, the preference between the 
two methods is not marked, provided constant intelligent care is given 
in equal measure to manipulation of both processes. 

"It cannot be denied, however, in the absence of such care, that 
if any irregularity occurs in the operation of the system, the rapid 
or mechanical filter would present the greater danger, by passing a 
much larger quantity of unfiltered water into the mains, before a 
proper correction is likely to be made. 

"As to the adaptability of the effluent for steaming purposes, the 
weight of evidence is decidedly in favor of s^w sand-filtration. It 
was found by the Filtration Commission of 1897, that the latter pro- 
cess caused less scale and less corrosive action on the plates of steam 
boilers. 

"Slow sand-filters are to be preferred from the standpoint of op- 
eration. Slight neglect or inattention, or mistaken judgment in the 
management of the filters, cannot at once seriously damage the efflu- 
ent. Rapid or mechanical filters require an exact proportionment of 
coagulant day by day. and sometimes hour by hour to obtain the de- 
sired results. While such careful attention can sometimes be attained, 





r-gpr ~~~| 


1 
1 

1 

BIRMINGHAM SAND. 


• 

pf - : &W Wlko SAND . •■ 




~7™ — "^^TT*'^^-" — "*^ 
If ■ '• " c *■• > "^ 

]; 

1 
■ 1 • ; 

■ 

1 ' a ■ 

i« .1 

a i 
GRANULATED QUARTZ- 1 


w "7 ^9 


<■■■*■■ 


j| « 


1 


IV • 


l^ROferf -B»UE£ .9UAPTZ. 



Fig. 8. — Showing Exact Size of Filtering Material Used in Con- 
struction of Sand Filter. (By courtesy of the Pittsburg Filter Manu- 
facturing Company.) 



EXAMINATION OF WATER. 93 

it nevertheless must be admitted that the simplicity of operation of the 
slow sand-filters is a decided advantage. 

"We therefore are of the opinion that slow sand-filtration as 
recommended by the Commission which reported to Council in 1899, 
is most suitable because : — 

"1. It is most simple and durable. 

"2. It is' most effective under existing circumstances. 
- "3. The cost of construction and operation is reasonable, and, 
according to careful estimates, no greater than for any other practic- 
able system." 

• Similar views are expressed in a very excellent report submitted 
by Mr. T. A. Leisen, chief engineer of the Wilmington Water De- 
partment. 

Other Methods of "Water Purification. — Of the other methods, 
the use of ozone is the only one deserving consideration. There is 
no doubt that ozone destroys the bacteria in the water without in any 
way changing its composition. However, the method is still in the 
experimental stage, and its utility on a large scale remains to be 
demonstrated. 



EXAMINATION OF WATER. 

The average consumer judges of the quality of the drinking- 
water by means of his special senses of sight, smell, and taste. Water 
which is turbid or emits a disagreeable odor is unreservedly con- 
demned, while clear, sparkling water free from odor is just as un- 
qualifiedly pronounced "pure." Those of us who are familiar with 
the history of typhoid epidemics and have had opportunity to examine 
drinking-water by means of special methods know how fallacious 
such a crude judgment is. Water that is clear and sparkling may 
contain the germs of typhoid fever or may be polluted with sewage 
which, in the course of decomposition, gave rise to carbonic acid. It 
takes many billions of bacteria to render a glass of water perceptibly 
turbid, and it requires considerable fresh sewage to impart to it a 
fecal odor. On the other hand, a turbid water, although objectionable 
from an esthetic point of view, may be entirely wholesome, and a dis- 
agreeable odor may be due to inoffensive vegetable compounds or 
harmless algae. 

This evident inability to form a ready judgment of the quality 
of a drinking-water has led the sanitarian to seek the aid of the 
chemist, who, it was supposed, could readily detect by means of 



*)4 TEXT-BOOK Otf HYGIENE. 

chemical analysis the injurious substances in the water under sus- 
picion. However, it soon became evident that a chemical analysis of 
water for sanitary purposes differs essentially from any other kind of 
analysis which the chemist may be called upon to make. The find- 
ing of arsenic or some poisonous alkaloid in a suspected fluid is 
decisive, and a report on such finding is merely a statement of fact. 
In the analysis of water, on the other hand, the findings are purely 
relative and must be properly interpreted before they can be of any 
value. A drinking-water, to use the legal phraseology, is indicted 
on circumstantial evidence, and it depends on the erudition and 
ability of the chemist to so interpret and connect the evidence- as 
to make out a clear case for or against the suspected water. 

The object of a chemical analysis of water is to discover whether 
or not pollution with objectionable organic impurities has taken 
place. By "objectionable organic impurities" we understand those 
which are from human or animal sources and are capable of convey- 
ing the germs of disease. In other words, we look principally for 
fecal contamination, inasmuch as the germs of typhoid fever, cholera, 
dysentery, and other intestinal disorders are excreted with the feces, 
and together with the feces gain access to the water. By itself, 
organic matter in the minute quantities in which it is present in 
water is not injurious to health, even if derived from sewage. It is 
only because this organic matter may be the carrier of disease germs 
that it becomes a matter for serious consideration. Therefore, organic 
matter derived from plants or vegetables removed from the possi- 
bility of infection with disease-producing bacteria has no significance 
from a sanitary standpoint, and its presence in drinking-water in no 
way renders it unwholesome. 

It is thus evident that the aim of the sanitary chemist is to dis- 
cover, first, the presence of organic matter which would indicate 
pollution, and, second, to determine the source of this organic matter. 
How well these two requirements are fulfilled by a chemical analysis 
will be made qlear later. 

Dead organic matter in water, as elsewhere, is not in a state of 
stability. Through the agency of certain bacteria, in the presence 
of oxygen, it continuously undergoes material changes, becoming 
resolved into simpler inorganic compounds. The nitrogenous sub- 
stances are converted into ammonia, and the latter into nitrous and 
finally nitric acid, the two acids combining with bases usually present 
to form nitrites and nitrates, respectively. These changes may be 
best illustrated by the following scheme: — 



EXAMINATION OF WATER. 95 

{Carbon — Carbon dioxide. 
Hydrogen f ^^ { ^te^' I Nitric acid 
Nitrogen j Ammonia j ^itntes) J (Nitrates ). 

This process, may it be remarked in passing, is a beneficial one, 
since by its means purification of polluted water is accomplished and 
the decaying organic matter converted into useful plant food. 

These changes, under favorable conditions, take place incessantly 
so long as there is a supply of dead organic matter and the neces- 
sary bacteria are present. Therefore, the amount of organic matter 
in water represents that portion which has not yet undergone disin- 
tegration — the organic nitrogen or so-called albuminoid ammonia — 
as well as the various intermediary products of the portion which 
has undergone or is undergoing disintegration — free ammonia, 
nitrites and nitrates. The quantitative relation of these products of 
oxidation to each other as well as to the unoxidized nitrogenous 
matter will depend on the original amount of the organic matter and 
the rapidity with which oxidation has taken place. Therefore, an 
analysis which discloses these various stages of oxidation reveals 
also not only the presence but the retrogressive course of the organic 
matter. Given a water containing relatively large amounts of albu- 
minoid and free ammonia, together with nitrites and nitrates, the 
indications would be that such water contains a large amount of 
organic matter in a state of incomplete oxidation; in other words, 
the contamination is recent. On the other hand, the presence of 
nitrates, in the absence of nitrites, with only small amounts of free 
and albuminoid ammonia, would indicate complete oxidation or a 
previous pollution. It goes without saying that pure water should 
contain only traces of albuminoid and free ammonia and should be 
free from nitrites and nitrates, the latter, if in small quantity, being 
rapidly appropriated by the water-plants. It is to be expected that in 
deep wells removed from the possibility of pollution, the water will 
contain very slight amounts of ammonia and no nitrites or nitrates, 
or mere traces, although free ammonia may sometimes be present 
in large amounts as a result of oxidation of vegetable matter or 
nitrates by ferric oxide. 

In addition to organic matter, water contains various salts, the 
most important and constant of which is sodium chloride, or, occa- 
sionally, magnesium and calcium chloride. These chlorides are de- 
rived from the sea or geological formations rich in salts. The 
amount of chlorides will varv with the natural source and remains 



90 TEXT-BOOK OF HYGIENE. 

fairly constant. However, when the water is polluted with sewage 
or household refuse the chlorides will increase in proportion to the 
degree and nature of the pollution, and this increase serves as a 
reliable indication of past or present pollution. This index, how- 
ever, is of value only when the normal chlorine contents of the water 
in question or of waters in the immediate neighborhood are known. 
There are a number of serious objections to the data obtained by 
a chemical analysis. (1) Excessive free ammonia in ground-waters 
may be the result, as has been mentioned, of the oxidizing action 
of iron or other metals on the nitrates present, while in surface waters 
it may be produced by the action of a fungus Crenothrix (Brown). 
(2) The nitrites found in deep-well water may be the result of the 
reduction of nitrates normally present in the soil and, consequently, 
in no way represent organic pollution. One of the chief objections, 
however, is that a chemical analysis does not reveal the nature of the 
organic matter, whether of vegetable or animal origin. Admitting 
that a certain water contains an excess of organic matter, the ques- 
tion arises, Does this organic matter represent harmless vegetables or 
dangerous sewage? The chemist cannot answer this question with a 
certainty which would preclude a "reasonable doubt/' Yet a water 
contaminated even with large amounts of vegetable matter, while not 
the best kind of water to drink, is nevertheless, free from danger. It 
is true, that if the ammonia on distillation is given off rapidly and 
the nitrites and chlorine are excessive, the indications that the organic 
matter is derived from sewage are reasonably clear, but the rapidity 
with which ammonia even from the animal matter is given off is only 
comparative and there is no way of gauging it, while a correct inter- 
pretation of the excessive amount of chlorine as compared with the 
normal chlorine standard of that particular locality presupposes a 
previous study of unpolluted waters which is seldom made and which 
often cannot be made. 

The other objection, one of a much more serious nature, is 
that water may be organically pure and yet contain germs of disease. 
Instances are cited by a number of authors showing that water- 
supplies pronounced on chemical evidence to be above suspicion have 
been proved to have caused serious epidemics of typhoid fever or 
dysentery. Thus Dr. Thresh, in his well-known book on ""Water and 
"Water-supplies," cites a number of such instances. 

The water from the river Ouse, below where it receives the sewage 
of Buckingham, to which an epidemic of typhoid fever was attrib- 



EXAMINATION OF WATER. 97 

uted, was analyzed by the public analyst, who reported that it "does 
not appear from the analysis to contain sewage matter." 

The Beverly water-supply, which became polluted with infected 
sewage from an asylum, giving rise to a typhoid epidemic, was pro- 
nounced by the chemist to be "of a very high degree of purity, and 
eminently suitable for drinking and domestic purposes." 

Analysis of water from the sewage-polluted Trent showed that 
"there is no evidence of the product of sewage contamination." 

The well-water supplying Houghton-le-Spring became contami- 
nated with sewage- from a farm, causing a sudden outbreak of typhoid 
fever. The chemist who analyzed the water reported that "this water 
is very free from indications of organic impurity. . . . It is a 
good water for drinking purposes." 

The reason for this evident failure on the part of the chemist to 
detect dangerous pollution is not difficult to find. A generally pure 
water may become contaminated with an amount of sewage too 
small to give evidence of its presence when diluted with several mil- 
lion gallons of water, yet this small amount of sewage may contain 
numerous specific germs the presence of which cannot be detected by 
a chemical analysis. Again, the sewage may have undergone com- 
plete oxidation and the end-products taken up by the plants, leaving 
no perceptible evidence of the pollution, while many of the specific 
germs which have been present in the original sewage remain viable 
and capable of causing disease. 

However, the employment of chemical analysis for comparing 
different waters in the same locality or a certain water at different 
times is of undoubted value. In this connection, the data obtained 
by a chemical analysis are both accurate and valuable. Also in the 
study of nitration, especially of the slow sand type, chemical analy- 
sis of the raw water and effluent made from time to time furnishes 
valuable evidence of the efficiency of the filter in removing turbidity 
and color, and bringing about the nitrification of organic matter 
which is the essential feature of this process of water-purification. 

Bacteriological Examination. — With the advent of bacteriology, 
and especially after the introduction of Koch's plate method of iso- 
lation of bacteria, the hopes of the sanitarian had been revived. It 
was supposed that at last we have a method by means of which we may 
detect the specific causes of disease in water, and thus place the ex- 
amination of water on the same certain basis as the detection of 
poisons. With the knowledge that typhoid fever is usually caused 
by the drinking-water and after the discovery by Koch that cholera is 



$g TEXT-BOOK OF HYGIENE. 

of similar origin, it was expected that the typhoid bacilli and the 
cholera spirilla could be detected in the suspected water. Unfortu- 
nately, disappointment followed all attempts in this direction. It 
soon became evident that while a certain water had been the cause 
of either a cholera or typhoid epidemic, as established by all evidence 
at hand, neither the cholera spirillum nor the typhoid bacillus could 
be detected in such waters. The cause for this failure was found in 
the great predominance of water bacteria which overgrow and obscure 
the few specific parasites, rendering their discovery impossible. The 
effort may be compared to looking for a needle in a haystack. While 
not entirely abandoned, the search for specific micro-organisms has 
not been made the object of routine examinations; and until some 
satisfactory method is devised by which the saprophytic bacteria may 
be entirely eliminated and the number of the specific micro-organisms 
increased so as to have them present in very small quantities of the 
water, the bacteriologist must depend upon other data upon which a 
conclusion as to the quality of the water may be reasonably based. 
It was thought for a time that the number of bacteria in the water 
could serve as an index of pollution, and a number of standards of 
bacterial purity have been suggested by various authors. Thus, Koch 
considers 100 bacteria per cubic centimetre as the safe limit for drink- 
ing-water; Miquel raises the standard to 1000; Crookshank agrees 
with this standard, while Mace and Migula claim that 250 to 500 
bacteria is the highest limit for a good drinking-water. These or any 
other arbitrary standards based on mere number of bacteria are as 
fallacious as the "standards" proposed from time to time for ammo- 
nias, nitrites, nitrates, etc. The number of bacteria in water will 
vary greatly with the medium, the reaction of the medium, the length 
of time the colonies are allowed to develop, dilution, etc. And there- 
fore, number alone, while indicating the presence of organic matter, 
does not necessarily show that the water contains pathogenic germs. 
This fact can be more readily ascertained by determining the num- 
ber of bacteria which develop on bile-agar 18 at body temperature and 
the presence or absence of bacillus coli. 

Dr. De Chaumont 19 classifies water under the four heads of 
Pure and Wholesome Water, Usable Water, Suspicious Water, and 

w The bile-agar medium is prepared according to the following formula: — 

Agar 1.5 gms. 

Sodium taurocholate 5 " 

Peptone 2.0 " 

Water 100 c. c. 

This is prepared as usual and 1 per cent, lactose added. 

"Parkes' Hygiene, vol. i, pp. 103-106. 



EXAMINATION OF WATER. 



99 



Impure Water. The characters of these waters are arranged in a 
series of tables, the essential details of which are given in Table XIV. 



Table XIV. 





Pure 


Usable 


Suspicious 


Impure 




Water. 


Water. 


Water. 


Water. 


Chemical 










Constituents. 












I. 


II. 


III. 


IV. 




Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Chlorine in solution . 


Under 1.4000 


Under 4.2857 


4-7 


Above 7.1428 


Solids " total . 


" 7.1428 


" 42.8571 


43-71 


" 71.4285 


" " volatile 


" 1.4000 


" 4.2857 


4-7 


" 7.1428 


Ammonia, free or sa- 










line 


" 0.0020 


" 0.0050 


0.0050-0.0100 


" 0.0100 


Ammonia, albuminoid 


" 0.0050 


" 0.0100 


0.0100-0.0125 


" 0.0125 


Nitric acid in nitrates 


" 0.0323 


" 0.5000 


0.5-1.0 


" 1 0000 


" " nitrites 


Nil. 


Nil. 


0.0500 


" 0.0500 


Nitrogen in nitrates . 


" 0.0140 


" 0.1129 


0.1243-0.2373 


" 2415 


Total nitrogen . . . 


" 0.0230 


" 0.1252 


0.1255-0.2465 


" 0.2601 


Oxygen absorbed by 










permanganate and 










acid within half an 










hour at 14(P F. . . 


" 0.0250 


" 0.1000 


0.1000-0.1500 


" 0.1500 


Total hardness . . . 


" 8.5 


" 17.3 


Above 17.0 


" 28.5 


Permanent hardness . 


" 3.0 


" 5.7 


" 5.7 


"■ 8.7 


Phosphoric acid in 










phosphates . . . 


Traces. 


Traces. 


Heavy traces. 


Heavy traces 


Sulphuric acid in sul- 










phates 


<< 


Under 3.000 


Above 3.000 


Above 4.2857 


Heavy metals . . . 


Nil. 


Traces. 


Traces. 


( Any except 
( iron. 
Present. 


Hydrogen sulphide . 


** 


Nil. 


Nil. 


Alkaline sulphides 


<« 


tt 


t* 


" 



Physical Characters. 
No. I. Colorless, or bluish tint; 
transparent, sparkling, and well aer- 
ated ; no sediment visible to naked 
eye; no smell; taste palatable. 

No. II. Colorless, or slightly green- 
ish tint; transparent, sparkling, and 
well aerated ; no suspended matter, 
or else easily separated by coarse 
filtration or subsidence; no smell; 
taste palatable. 

No. III. Yellow, or strong, green 
color; turbid; suspended matter con- 
siderable; no smell, but very marked 
taste. 

No. IV. Color, yellow or brown; 
turbid, and not easily purified by 
coarse filtration; large amount of 
suspended matter; very marked smell 
or taste. 



Microscopical Characters. 
No. I. Mineral matter; vegetable 
forms with endochrome; large animal 
forms, no organic debris. 

No. II. Same as No. I. 



No. III. Vegetable and animal 
forms more or less pale and colorless; 
organic debris; fibres of clothing, or 
other evidences of house-refuse. 

No. IV. Bacteria of any kind; 
fungi; numerous vegetable and ani- 
mal forms of low types; epithelia, or 
other animal structures; evidences of 
sewage; ova of parasites, etc 



100 TEXT-BOOK OF HYGIENE. 

Methods of Water Analysis. — Turbidity. — This may be de- 
termined either by the platinum wire method or by comparison of the 
sample with known quantities of silica suspended in water. The 
standard of turbidity adopted by the United States Geological Survey 
is "a water which contains 100 parts of silica per million in such a 
state of fineness that a bright platinum wire one millimetre in diam- 
eter can just be seen when the centre of the wire is 100 millimetres 
below the surface of the water, and the eye of the observer is 1.2 
metres above the wire. The observation being made in the middle 
of the day, in the open air, but not in sun-light, and in a vessel that 
the sides do not shut out the light so as to influence the results. The 
turbidity of such water shall be 100." 20 . To carry out this method, a 
wooden rod 5 feet long and 1 inch square is taken and a small plati- 
num wire 1 millimetre in diameter inserted about 1 inch from the 
end. The rod is then graduated, the mark of 100 being placed at a 
distance of 100 millimetres from the centre of the wire. The inter- 
mediary graduations are made according to a table furnished by the 
United States Geological Survey (Circular No. 8, 1902). The mark 
on the rod at which the platinum wire vanishes is the turbidity in 
parts per million. The silica method, which is much more convenient, 
consists of a standard suspension of one gramme of dried diatoma- 
ceous earth in one litre of distilled water. This represents a turbidity 
of 1000 parts per million. From this stock suspension, standards for 
comparison are prepared by diluting certain quantities with distilled 
water. Thus 1 c. c. diluted with 100 c. c. of water equals a turbidity 
of 10 parts per million. The comparison is made in 100 c. £. Nessler 
tubes or glass-stoppered bottles. 

Significance. — Turbidity is objectionable from an esthetic stand- 
point, although highly turbid 'water may be entirely wholesome, and 
vice versa. How T ever, no one likes to drink muddy water, and for this 
reason turbidity enters as an important factor in determining the 
quality of a given water or in deciding upon the desirability and 
methods of filtration. 

Color. — The color of a water is determined by comparing 100 
c. c. of the sample with an equal quantity of a standard prepared from 
a solution containing 1.246 grams of potassium platinic chloride per 
litre. This solution has a color of 500. 

Significance. — Color in water has the same significance as tur- 
bidity, and unless due to organic or inorganic impurities such as 



^Report of Committee on Standard Methods of Water Analysis, Amer- 
ican Public Health Association, 1905. 



EXAMINATION OF WATER. 101 

sewage or dyes, has no effect on the quality of the water from a purely 
hygienic standpoint. 

Odor. — The odor is determined by violently shaking a bottle half 
full of the sample and then smelling it. The odor generated by heat- 
ing is determined as follows : About 150 c. c. of the sample are poured 
into a 400 c.c. beaker. The beaker is covered, placed on a hot plate, 
and heated to just below boiling. The beaker is then shaken and the 
odor detected by the smell. 

Significance.^— The odor of water may indicate its source as well 
as the presence of sewage. Objectionable odors, however, may be 
caused by certain micro-organisms. Thus, a "fishy" odor is caused 
by JJroglena, an "aromatic" or "rose geranium" odor by Asterionella, 
and a "pig-pen" odor by Anabena. A very disagreeable odor is caused 
also by Crenothrix. 

Total Solids. — This is determined by evaporating 100 c.c. of 
the water in a weighed platinum dish, drying the residue in an oven 
at 105° C. for thirty minutes, and then weighing. The weight of the 
residue in milligrams equals parts per million. 

Organic Nitrogen. — The presence and amount of organic nitro- 
gen in a given water are determined as free ammonia, albuminoid am- 
monia, nitrites, and nitrates. These substances represent the various 
stages of decomposition which organic nitrogen undergoes in its 
transformation from a complex to a simple compound. 

Free Ammonia. — This is determined by distilling 500 c. c. of the 
sample in a flask connected with a condenser. The distillate is col- 
lected in glass cylinders (Nessler tubes) and a small amount of 
Nessler reagent 21 added and the distillate compared with standards 
prepared by adding definite quantities of ammonium chloride to pure 
water. As a rule 150 c. c. of the first distillate contain all of the 
free ammonia. 

Albuminoid Ammonia. — After the free ammonia is distilled off, 
the distillation is interrupted and 50 c. c of an alkaline solution of 
potassium permanganate 22 added. The distillation is resumed and 
carried on until four or five Nessler tubes are collected. The distil- 
late in each tube is then treated as above. 

Nitrites. — One hundred c. c. of the sample are decolorized, if 

21 This reagent reacts with minute quantities of ammonia. It is made 
by dissolving 50 gms. of potassium iodide in water and adding a saturated 
solution of mercuric chloride, enough to produce a permanent precipitate. 
400 c. c. of a 50-percent, solution of potassium hydrate are added, and the 
whole diluted to one litre. 

22 This is prepared by dissolving 200 gms. of potassium hydroxide and 8 
gms. of potassium permanganate in a litre of distilled water. 



102 TEXT-BOOK OF HYGIENE. 

necessary, with aluminum hydrate and poured into a 100 c. c. Nessler 
tube. To this are added 1 c. c. of sulphanilic acid solution (8 
grammes of sulphanalic acid in 1000 c. c. of dilute acetic acid, specific 
gravity 1.04) and 1 c. c. naphthylamine solution (5 grammes of 
naphthylamine in 1000 c. c. of dilute acetic acid). The tube is cov- 
ered, allowed to stand for ten minutes, and the resulting pink color 
compared with standards containing definite amounts of sodium 
nitrite in solution, the standards having been treated in the same 
manner as the sample. 

Nitrates. — Twenty c. c. or less of the sample are evaporated on 
a water-bath and the residue treated with 1 c. c. of phenolsulphonic 
acid (phenol, 30 grammes; concentrated sulphuric acid, 370 
grammes). About 10 c. c. of water are added and enough ammonia 
to render the liquid alkaline. The liquid is then transferred to a 
100 c. c. Nessler tube, distilled water added to the 100 c. c. mark, and 
the yellow color matched with standards containing definite amounts 
of potassium nitrate, and treated as above. 

Significance. — With the exception of deep waters, which may 
contain large amounts of nitrogen as free ammonia (clue to reduction 
of nitrates) and still be pure, the presence of excessive quantities of 
organic nitrogen indicates pollution. An excess of free ammonia 
(above 0.06 parts per million), especially if nitrites are present, 
points to recent pollution, while an excess of nitrates (above .2 parts 
per million for surface-waters and 2 parts per million for ground- 
waters) points to past pollution. As to albuminoid ammonia, Wank- 
tyn holds that if the water contains above 0.10 per million it begins 
to be very suspicious, and if over 0.15 parts per million, it should be 
condemned absolutely. This standard is regarded by Mason as too 
rigorous. 

Oxygen Consumed. — One hundred c. c. of the sample are meas- 
ured into a flask, 10 c. c. of dilute sulphuric acid 23 and 10 c. c. of 
solution of potassium permanganate 24 added; the flask is then placed 
in a bath of boiling water and kept there for exactly thirty minutes. 
At the end of that period, the flask is removed, 10 c. c. of ammonium 
oxalate solution 25 added, and the clear fluid titrated with the stand- 
ard permanganate solution until a faint but distinct color is obtained. 



23 One part of sulphuric acid to 3 parts of distilled water. 

24 This standard solution contains 0.4 gm. of potassium permanganate in 
one litre of distilled water. 

25 This solution contains 0.888 gm. of ammonium oxalate in one litre. 
One c. c. of this solution should neutralize one c. c. of the permanganate. 



EXAMINATION OF WATER. 103 

Each cubic centimetre of the standard permanganate in excess of 
the oxalate solution represents 0.0001 gram of oxygen consumed by 
the sample. This, multiplied by 10, equals parts per million. 

Significance. — This determination indicates the presence of or- 
ganic carbon. If the oxygen required is high and the ammonias ex- 
cessive, the indications are that the pollution is of vegetable origin; 
while if the ammonias are high and the oxygen required low, the pol- 
lution is in all probability animal in character. 

Chlorine. — Solutions required: 1. Standard silver-nitrate solu- 
tion. To 1 litre of pure distilled water add 4.788 grammes of pure 
silver nitrate (AgN0 3 ). One cubic centimetre of this solution is 
equivalent to 1 milligramme of chlorine. 2. Potassium-chromate solu- 
tion. A 10-per-cent. solution of potassium chromate (K 2 Cr0 4 ) in dis- 
tilled water free from chlorine. 

Process : To 100 c. c. of the water to be tested add a few drops 
of the potassium-chromate solution, and then run in the silver-nitrate 
solution from a graduated burette, adding it drop by d*ro]5 and stirring 
the water continually with a glass rod. Continue until a faint but 
permanent orange-red tint has been produced, showing that all the 
chlorine has been combined with the silver, the persisting reddish tint 
being due to silver chromate. The number of cubic centimetres of 
silver-nitrate solution used indicate the number of milligrammes of 
chlorine in 100 c. c. of the water, or the parts per 100,000;* this multi- 
plied by 10 gives the number of milligrammes of chlorine in 1 litre, 
or parts per million. If the water contain but little chlorine, the test 
will be more accurate if 250 c. c. of the water be first evaporated over 
a water-bath to about 50 c. c. before proceeding as above : four times 
the result will then give the number of milligrammes of chlorine in 
1 litre. Should it be desired to express the proportion in terms of 
sodium chloride, multiply the result, obtained as above, by 1.648 ; or 
make up the silver-nitrate solution by adding 2.905 grammes to the 
litre, each cubic centimetre of this solution being then equal to 1 milli- 
gramme of sodium chloride. 

Significance. — Chlorine, or its compounds, when present in 
drinking-water, indicates generally sewage pollution. It is true that 
chlorine may be in excess in water, and the latter, nevertheless, be 
entirely free from sewage or urine, but this occurs only-where there is 
a natural deposit of chlorine compound in the soil from which the sup- 
ply is drawn. If communication with the sea or salt-deposits is 
excluded, the chlorine may be assumed to be due to the inflow of 



104 TEXT-BOOK OF HYGIENE. 

Hardness. — Solutions required: 1. Soap solution. Dissolve 
about 10 grammes of Castile or soft soap in 1 litre of weak (35 per 
cent.) alcohol. 2. Standard lime solution. Dissolve 1.11 grammes 
pure calcium chloride in 1 litre of distilled water. One cubic centi- 
metre of this solution is equivalent to 1 m. g. of calcium carbonate 
(CaC0 3 ). Process: First, find how much of the soap solution is 
needed to make a lather with 100 c. c. of distilled water, as follows: 
Place the water in a flask holding about 250 c. c. and run in the 
soap solution from a burette, a few drops at a time, corking and shak- 
ing the flask well after each addition. The lather should have a depth 
of about one-fourth of an inch, and should be permanent for at least 
five minutes. Then standardize the soap solution by diluting 5 c. c. 
of the standard lime solution to 100 c. c. with distilled water and find- 
ing how many cubic centimetres of the soap solution are necessary to 
make a permanent lather with it. This quantity, less the number of 
cubic centimetres needed to make a lather with the 100 c. c. of dis- 
tilled water, "represents the amount of soap solution that will neutral- 
ize 5 m. g. of calcium carbonate or its equivalent. Lastly, determine 
in the same way the number of cubic centimetres of soap solution 
necessary to make a permanent lather with 100 c. c. of the water to be 
examined ; subtract the quantity necessary for 100 c. c. distilled water 
and estimate the amount of calcium carbonate or its equivalents pres- 
ent, as follows : For example, it takes 2 c. c. of soap solution to make 
a lather with the distilled water and 12 c. c. with the diluted lime 
solution. Then, 12 — 2 = 10 c. c. = 5 m. g. calcium carbonate, and 
each cubic centimetre of the soap solution = 0.5 c. c. of the standard 
lime solution, or 0.5 m. g. calcium carbonate. Consequently, if 100 
c. c. of the water examined require 17 c. c. of soap solution, it must 
contain (17 — 2) X 0.5 = 7.5 m. g. calcium carbonate or its equiva- 
lent, and 1 litre of the water contains 75 m. g. calcium carbonate. 

Lead, Copper, and Iron. — To 50 or 100 c. c. of the water in a 
white porcelain dish, or in a tall glass jar, over white paper, add a 
few drops of ammonium sulphide, — (N"H 4 ) 2 S. A dark coloration 
or precipitate indicates the presence of either lead, copper, or iron, due 
to the formation of the respective sulphide. Then add a few drops of 
hydrochloric acid (HC1). If the color disappear, iron only is pres- 
ent; if it persist, lead or copper is present. In the latter case, add 
a few drops of acetic acid and about 1 c. c. of a strong solution of 
pure potassium cyanide. If the color disappear, it is due to copper; 
if it remain, lead is present. If lead only is present in the water, the 
above test will detect 1 / 10 grain per gallon. The above test may be 



EXAMINATION OF WATER. 105 

corroborated as follows: Partly fill two test-tubes with the original 
water; to one add a little potassium-chromate solution; an opacity 
and the deepening of the color to a canary yellow indicates lead. To 
the second add a drop of dilute hydrochloric acid and a few drops of 
potassium-ferrocyanide solution; a blue color indicates iron, either 
ferrous or ferric; a bronze or a mahogany-red color indicates copper. 
Quantitative tests for the above metals may be made by making 
standard solutions of the respective elements, treating a measured 
quantity of the original water with the proper reagent, as indicated, 
and comparing the color produced with that given by a definite quan- 
tity of the respective standard solution. 

Phosphates. — Solution required, ammonium molybdate: Dis- 
solve 10 grammes of molybdic anhydride in 41.7 c. c. of ammonia 
(XH 4 H0), — sp. gr. 0.96, — and pour slowly into 125 c. c. of nitric 
acid (HX0 3 ), — sp. gr. 1.20; allow to stand in a warm place for sev- 
eral days till clear. Process : slightly acidify 500 c. c. of the water 
with nitric acid, evaporate to about 50 c. c, add a few drops of ferric 
chloride (Fe 2 Cl 6 ) and ammonia in slight excess. Filter, dissolve the 
precipitate in the smallest possible quantity of nitric acid, and evap- 
orate to 5 c. c. Heat nearly to boiling ; add 2 c. c. of ammonium- 
molybdate solution; keep solution warm for one-half hour. If there 
is an appreciable quantity of precipitate, collect it on a small, weighed 
filter-paper, wash with distilled water, dry at 100° F., and weigh. 
The weight of the precipitate multiplied by 0.05 gives the amount 
of phosphates as P0 4 in the 500 c. c. of water. 

Bacteriological Examination. — The following method of proced- 
ure has been recommended by the committee on laboratory methods 
of the American Public Health Association: — 

Media. — The standard medium for determining the number of 
bacteria in water shall be nutrient gelatin, and for polluted waters 
w r hich cannot be plated promptly after collection agar may be substi- 
tuted. All variations from these two media shall be considered as 
special media. If any medium other than standard gelatin is used, 
this fact shall be stated in the report. For general work the standard 
reaction shall be 1 per cent, acid, but for long-continued work upon 
water from the same source the optimum reaction shall be ascertained 
by experiment and thereafter adhered to. If the reaction used, how- 
ever, is different from the standard, it shall be so stated in the report. 

Procedure. — Shake at least twenty-five times the bottle which 
contains the sample. Withdraw 1 c. c. of the sample with a sterilized 
pipette and deliver it into a sterilized Petri dish 10 centimetres in 



106 TEXT-BOOK OF HYGIENE. 

diameter. If there is reason to suspect that the number of bacteria is 
more than 200 per cubic centimetre, mix 1 c. c. of the sample with 
9 c. c. of sterilized tap or distilled water, and so on. Shake twenty- 
five times and measure 1 c. c. of the diluted sample to a Petri dish. 
If a higher dilution is required, proceed in the same manner, e.g., 
1 c. c. of the sample to 99 c. c. of sterilized water, or 1 c. c. of the once 
diluted sample to 99 c. c. of sterilized water, and so on. In the case 
of an unknown water it is advisable to use several different dilutions 
for the same sample. To the liquid in the Petri dish add 10 c. c. of 
standard gelatin at a temperature of about 30° C, or 10 c. c. standard 
agar at a temperature of about 40° C. Mix the medium and water 
thoroughly by tipping the dish back and forth, and spread the con- 
tents equally over the bottom of the plate. Allow the gelatin to cool 
rapidly on a horizontal surface and transfer to the 20° C. incubator 
as soon as it is hard. Incubate the culture for forty-eight hours at a 
temperature of 20 °C. in a dark, well-ventilated incubator where the 
atmosphere is practically saturated with moisture. After this period 
of incubation place the Petri dish on a glass plate suitably ruled, and 
count the colonies with the aid of a lens which magnifies at least five 
diameters. So far as practicable, the number of colonies upon the 
plate shall not be allowed to exceed 200. The whole number of col- 
onies upon the plate shall be counted, the practice of counting a 
fractional part being resorted to only in case of necessity. 

When agar is used for plating, it will be found advantageous to 
use Petri dishes ♦with porous earthenware covers in order to avoid 
the spreading of colonies by the water of condensation. 

For the detection of B. coli and other specific bacteria consult 
text-book on bacteriology. 



QUESTIONS TO CHAPTER II. 

WATER. 

For what purposes do people need water? Why should the supply be 
pure? What is the quantity needed by each person daily, and what quantity 
should be supplied per head in towns and cities for all purposes? How may 
waste of water be prevented? What is the objection to the use of water- 
meters ? 

What is the original source of all fresh water? How is rain-water usually 
collected and stored? What are the objections to underground cisterns? What 
is the only material of which underground cisterns should be made? 

From what source do most cities and towns derive their water-supply? 
What precautions must be observed regarding such a source? What are some 
of the minor objections to the use of river-water? What peculiar diseases 
may be due to such water? What is the most serious objection to the use 
of river- water for domestic purposes? 

How does a running stream purify itself? Can this self -purification be 
relied upon? Can it be stated definitely when a stream once polluted becomes 
fit for use again? Is it safe to use water from a stream known to have been 
contaminated by sewage? 

What is usually the quality of water from fresh-water lakes and ponds? 
What large city uses lake-water entirely? What precautions must be observed 
regarding such a source of supply? To what is the offensive taste and odor 
of water from small lakes or storage-reservoirs often due? 

Does water purify itself absolutely in freezing? What matters may be 
found in ice? Are all pathogenic micro-organisms destroyed by freezing? 
What part of ice is the purest ? 

What class of peisons usually derive their drinking-water from springs 
and wells? What is the relative purity of spring- and of well-water? Why? 
What changes take place in diluted organic matter in percolating through the 
soil? To what are these changes due? What may retard or check these 
changes? Is water containing nitrites and nitrates necessarily dangerous? Of 
what are nitrites and nitrates an indication? 

Name some of the qualities that are desirable in water for drinking or 
domestic purposes. When is a water said to be hard? 

To what is the hardness of water due? What is the distinction between 
"removable" or "temporary" and "permanent" hardness, and what is meant 
by "total" hardness? How is the degree of hardness determined, and upon 
what does the test depend? Describe the test. Why is hard water objection- 
able for domestic use? 

(107) 



108 TEXT-BOOK OF HYGIENE. 

What diseases and derangements of health may be due to hard water? 
Is the evidence absolute regarding all of these? What troubles may large 
amounts of suspended mineral matter cause? How may such water be clari- 
fied? What mineral in the water is essential to the process? 

What may be the effect of large quantities of organic matter in the 
water? What infectious diseases may be due to impure drinking-water? What 
other organisms harmful to health, other than bacteria, may be found, in drink- 
ing-water? Name some notable places where epidemics have been undoubt- 
edly caused by impure drinking-water. How may a milk-supply be infected 
by impure water ? How might a water be polluted in distribution, even though 
the source be pure? 

What is the advantage of a prolonged storage of river-water? What 
waters should not be stored in lead-lined cisterns or conveyed in leaden pipes? 
What is the greatest amount of lead permissible in water? 

In what ways may water be purified on a large scale? Explain the process 
of sand filtration. 

What methods may be used in the household for the purification of 
water? How may the water be softened? How may disease germs and other 
organisms in water be destroyed? How may organic matter be removed? 
What are some good filtering materials? What are some of the essential 
requisites of a good house-filter? What is necessary that every house-filter 
may be safe for use? Are any filters absolutely germ-proof? 

How are the color, transparency, and odor of water determined, and 
what is the standard of comparison? Is a turbid or colored water necessarily 
harmful, and may a perfectly-clear water be dangerous to use? 

How are the total solids of a water determined quantitatively? Describe 
the permanganate-of-potash test for the determination of the organic matter 
in water. What does an excess of chlorine or chlorides in water generally 
indicate, and why? How may these be determined quantitatively? If sewage 
contamination of a water be suspected, how may the suspicion be confirmed? 
Why should the presence of nitrites or nitrates in water excite the suspicion 
of sewage contamination. Give a test for each. By what reagent is the 
presence of ammonia determined? 

How may we know whether an excess of chlorides is due to sewage con- 
tamination or not? What is the probable source of ammonia if in excess and 
in company with nitrates, etc. ? Which is supposed to indicate the most recent 
contamination, nitrites or nitrates? What does the presence of nitrates with- 
out nitrites or ammonia indicate? What lime-salt is most readily removed by 
boiling? 

What relation has the organic matter to the nitric acid? 

Into what four classes may water be divided? Name some of the char- 
acteristics of these different classes. 

What are the solutions needed in the quantitative test for chlorine? 
What is the strength of each, and what is the relation of the silver-nitrate 
solution to chlorine? What is the use of the potassium-chromate solution? 



QUESTIONS TO CHAPTER II. 109 

How may the result be expressed? What solutions are used in testing for 
nitrates quantitatively? 

In testing for hardness, why is a standard lime solution necessary? What 
should be the characteristics of the lather produced by the soap solution? 
Why is alcohol used as a solvent for the soap? What is the underlying prin- 
ciple of this test? 

How may lead, copper, or iron be detected in water? How may you 
distinguish between the respective sulphides of the above metals? How may 
the above test respecting any one of the metals be corroborated? How deli- 
cate is the test, as regards lead? How might a quantitative determination of 
these metals be made? What is the principal reagent used in the test for 
phosphates? 

How may a bacteriological examination of water be made? What pre- 
cautions must always be observed in such examinations? 



CHAPTER III. 



FOOD. 



In order to preserve health and vigor it is necessary for animal 
beings to consume at intervals a sufficient quantity of substances 
known as food. Alimentary substances, or foods, may, therefore, be 
briefly denned as materials which, taken into the body and assim- 
ilated, sustain the processes of life, promote growth, or prevent de- 
struction of the organized constituents of the body. 

According to Atwater, 1 a food is a "material which, when taken 
into the body, serves to either form tissue or yield energy, or both." 
This definition includes all the ordinary food-materials, since they 
build tissue as well as yield energy ; but it excludes creatin, creatinin, 
and other so-called meat-extractives and likewise thein or caffein 
of tea and coffee, as they neither build tissue nor yield energy. 

QUANTITY AND CHARACTER OF FOOD NECESSARY. 

It has long been known, as the result of the empirical observa- 
tion of feeding large bodies of people, that the various proximate 
principles composing the tissues must be combined in certain definite 
proportions in the food in order to preserve the normal degree of 
health and vigor of the body. Within a comparatively recent period 
physiologists have made experiments upon animals and human beings 
which have led to the same conclusions, and have enabled these pro- 
portions to be fixed with more or less exactness. 

Considering man as an omniverous animal, it may be laid down 
as an invariable rule that the following four alimentary principles 
are necessary to his existence. 2 Neither of these principles can be 
dispensed with for a prolonged period without illness or death re- 
sulting. 

1. Water. — This must be supplied in sufficient quantity to permit 
the interchange of tissue to be carried on in the body. 

2. Salts. — Inorganic compounds of various kinds are necessary 
to the preservation and proper construction of the tissues. They are 
all found in sufficient quantities in the various alimentary substances 



X U. S. Department of Agriculture, Bui. No. 21. 
2 Physiologie, Landois, 2te AufL, p. 448. 

(110) 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



Ill 



consumed by man and the lower animals. A deficiency of inorganic 
constituents in the food is followed by disease. 

3. Proteids. — Organic nitrogenous material, either animal or 
vegetable, is a necessary constituent of the food of man. Continued 
existence is impossible without a sufficient supply of nitrogenous 
substances. 

4. Fats or Carbohydrates. — The organic non-nitrogenous or car- 
bonaceous principles of food are also necessary to the continuance of 
health. They are supplied either by fats or by carbohydrates (sugar, 
starch, etc.), which may, within certain limits, be used as substitutes 
for each other. Voit has shown that 17 parts by weight, of starch, 
are equivalent as carbonaceous or oxidizable food to 10 parts of fat. 

The physiology of nutrition has been very carefully studied by 
a large number of experimental physiologists, who have arrived at 
conclusions differing widely from those generally accepted by the 
older writers on the subject. The division of foods into plastic and 
respiratory foods, or, in a general way, into proteids, or muscle- 
builders, and fats and carbohydrates, or oxidizing foods, is now no 
longer recognized in science. It has been established that proteid tis- 
sues are not alone the result of proteid food, and that the accumula- 
tion of fat in the body is not altogether due to the excessive con- 
sumption of fats and carbohydrates. It has been further shown, con- 
trary to the general belief, that the nitrogenous or proteid tissues are 
not used up during hard labor any faster than when at perfect rest, 
but that, on the contrary, increased muscular exertion is attended by 
increased consumption of stored-up fat. 

These facts have led to a modification of the standard dietaries 
formerly employed. At present the standards of the quantity of food 
principles required to maintain equality between bodily income and 
expenditure are those calculated by Professor Voit, and Professor 
Atwater in this country, after many experiments upon human beings 
and the lower animals. These standards are as follow: — 



Table XV. 

ADULT MALE OF AVERAGE WEIGHT. 





At Rest. 


Moderate Labor. 


Severe Labor. 


Proteids .... 

Pats 

Carbohydrates . . 


110 grammes 

50 " 
450 " 


118 grammes 
50 " 
500 " 


145 grammes 
100 " 
500 " 



112 



TEXT-BOOK OF HYGIENE. 



Table XVI. 

Comparative Cost of Digestible Nutrients and Energy in Different Food Materials 

of Average Prices.* 

[It is estimated that a man at light, to moderate muscular work requires about 0.23 pounds of 

protein and 3,050 calories of energy per day.] 



Kind of Food Material 



Beef, sirloin 

Beef, sirloiu 

Beef, sirloin 

Beef, round 

Beef, round 

Beef, round 

B^ef, shoulder clod .... 

Beef, shoulder clod 

Beef, stew meat 

Beet, dried, chipped . . . . 

Mutton Chops, loin 

Mutton, leg 

Mutton, leg 

Roast pork, loin 

Pork, smoked ham 

Pork, smoked ham 

Pork, fat salt 

Codfish, dressed, fresh . . . . 

Halibut, fresh 

Cod, salt 

Mackerel, salt, dressed . . 

Salmon, canned 

Oysters, solids, 50 cts. per qt 
Oysters, solids, 35 cts. per qt, 

Lobster, canned 

Butter 

Butter 

Butter 

Eggs, 36 cents per dozen . . . 
Eggs, 24 cents per dozen . . . 
Eggs, 12 cents per dozen . . 

Cheese 

Milk, 7 cents per quart . . . 
Milk, 6 cents per quart . . . . 

Wheat flour 

Wheat flour 

Corn meal, granular . . . . 
Wheat breakfast food . . . . 

Oat breakfast food 

Oatmeal 

Rice 

Wheatbread 

Wheat bread 

Wheat breal 

Rye bread 

Beans, white, dried 

Cabbage 

Celery 

Corn, canned 

Potatoes, 90 cents per bushel . 
Potatoes, 60 cents per bushel . 
Potatoes, 45 cents per bushel . 

Turnips 

Apples .... 

Bananas 

Oranges ... . . . . 

Strawberries 

Sugar 



.a 3 

M o 

PkPk 



Cents 

25 

20 

15 

16 

14 

12 

12 

9 

5 

25 
16 
20 
16 
12 
22 
18 
12 
10 
18 

7 
10 
12 
25 
18 
18 
20 
25 
30 
24 
16 

8 
16 

zy 2 



% 



5 
4 
5 
5 

?> 

10 

;x 



<~3.2 

O 3 <B 



Dollars 

1.60 

1.28 

.96 

.87 

.76 

.65 

.75 

.57 

.35 

.98 

1.22 

1.37 

1.10 

.92 

160 

1.30 

6.67 

.93 

1.22 

.45 

.74 

.57 

4 30 

3.10 

1.02 

20.00 

25.00 

30.00 

2.09 

1.39 

.70 

.64 

1.09 

.94 

.31 

.26 

.32 

.73 

.53 

.29 

1.18 

.77 

.64 

.51 

.65 

.29 

2.08 

6.65 

4.21 

1.00 

.67 

.50 

1.33 

5.00 

10.00 

12.00 

8.75 



oO 60 

all 



Cents 
25 
20 
15 
18 
16 
13 
17 
13 

7 
32 
11 
22 
18 
10 
13 
11 

3 
46 
38 
22 

9 

13 

111 



Amounts for 10 Cents 






Pounds 
0.40 
.50 
.67 
.63 
.71 



.40 
.63 
.50 
.63 
.83 
.45 
.56 
.83 

1 
.56 

1.43 

1 
.83 
.40 
.56 
.56 
.50 
.40 
.33 
.42 
.63 

1.25 
.63 

2.85 

3.33 

3.33 

4 

4 

1.33 

1.33 

2.50 

1.25 

1.67 

2 

2.50 

2 

2 

4 

2 

1 



10 

13.33 

10 
6.67 
1.43 
1.67 
1.43 
1.67 



Pound 
0.06 

.08 

.10 

.11 

.13 

.15 

.13 

.18 

.29 

.10 

.08 

.07 



Pound 
0.06 



.01 



O-o 



Pounds 



.02 

.14 

.17 

2 45 

2.94 

2 96 



1.66 

.97 

.87 

1.04 

1.30 

104 

1.16 

.18 

.05 

.18 

.93 

1.40 

187 

.54 

.65 

.18 

.13 

.00 

1.67 



Calories 

410 

515 

685 

560 

630 

740 

595 

795 

1,530 

315 

890 

445 

560 

1,035 

735 

915 

2,950 

220 

262 

465 

1,135 

760 

90 

125 

225 

1,705 

1,365 

1,125 

260 

385 

770 

1,185 

885 

1030 

5,440 

6,540 

6,540 

2,235 

2,395 

4,500 

2.025 

2.000 

2,400 

3,000 

2,340 

3,040 

460 

130 

430 

1,970 

2,950 

3,935 

1,200 

1,270 

370 

250 

215 

2,920 



aprinciples of Nutiition and Nutritive Value of Food. By W. O. Atwater. U. S. Dept. 
Agr. Bull. No. 142. 

•*The cost of 1 pound of protein means the cost of enough of the given material to furnish 
1 pound of protein, without regard to the amounts of the other nutrients present. Likewise the 
cost of energy means the cost of enough material to furnish 1,000 calories without reference to the 
kinds and proportions of nutrients in which the energy is supplied. These estimates of the cost 
of protein and energy are thus incorrect in that neither givei credit for the value of the other. 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 113 

As the average weight of women is less than that of men, a re- 
duction of from 15 to 20 per cent, in the various food principles may 
be made for the female ration. 

The relative proportion of nitrogenous to non-nitrogenous prin- 
ciples in this ration is about 1 to 5. In the older diet standards, e.g., 
Moleschott's, the proportion of nitrogenous to non-nitrogenous prin- 
ciples is much larger, being, for a man at moderate labor, proteids, 
130 grammes; fats, 84 grammes; and carbohydrates, 404 grammes, 
or about 1 to 3.75. 

While from ignorance, or motives of economy, many men sustain 
life and preserve health at hard labor on rations varying considerably 
from the standard above given, it is probable that, all things being 
considered, the most perfect physiological ration would also be the 
most economical. Thus, Professor Vaughn proposes a- daily ration 
consisting of bread, cod-fish, lard, potatoes, bacon, beans, milk, sugar, 
and tea in such proportions as to furnish 123 grammes proteids, 70 
grammes fats, and 550 grammes carbohydrates. The total cost or 
money value of this ration at present prices is about thirteen cents. 
In actual food value it is not inferior to the daily fare of the habitue 
of Delmonico's. (See Table XVI.) 

In estimating the food requirements of the organism, account 
is taken of the fact that the body takes in potential energy in the 
form of food and generates kinetic energy in the form of heat and 
motion. 

"Heat and muscular power are forms of force or energy. The 
energy latent in the food is developed as the food is consumed in the 
body. The process is more or less akin to that which takes place when 
coal is burned in the furnace of the locomotive. For the burning of 
the food in the body or the coal in the furnace, air is used to supply 
oxygen. When the fuel is oxidized, be it meat or wood, bread or coal, 
the latent energy becomes active, or, in technical language, the poten- 
tial energy becomes kinetic; it is transformed into heat and power. 
As various kinds of coal differ in the amount of heat given off per ton, 
so various kinds of food and food ingredients give off different 
amounts of energy ; that is, have different values as fuel in the body." 5 

The unit of measurement of the fuel-valve of food is a calorie, 
which is the amount of heat required to warm one gramme of water 
one degree centigrade. One calorie is equal to about 1.54 foot-tons; 
in other words, one calorie, when transformed into mechanical power, 
would lift one ton 1.54 feet. 

5 Atwater. U. S. Department of Agriculture, Bull. No. 142. 



114 



TEXT-BOOK OF HYGIENE. 



Table XVII. 

Standard Dietaries (Hutchison). 
For a man at moderate muscular work. 



Food Materials 


Amount 


Proteids 


Fats 


Carbo- 
hydrates 


Fuel Value 


I. 
Beef, ronnd steak 


Ounces 

13 

3 

6 
22 


Pounds 

0.14 

6.' 02* 
12 


Pounds 

0.12 
0.16 

6.02 


Pounds 
0.75 


Calories 

695 


Butter. . . 


680 


Potatoes 


320 


Bread 


1760 








44 


0.28 


0.30 


0.90 


3455 


II. 
Pork, salt 


4 
2 

16 

8 


'6!23' 
0.04 


0.21 
0.11 
0.02 
0.01 


6.59 
0.28 


880 


Butter 


450 


Beans 


1615 


Bread 


640 








30 


0.27 


0.35 


87 


3585 


III. 
Beef, neck 


10 
1 

16 

16 
4 

16 
3 


0.10 

o!o4' 

0.02 
0.04 
0.09 


0.09 
05 
0.04 

'add' 

0.02 


'6.05* 
0.15 
0.17 
0.56 
0.19 


550 


Butter 


225 


Milk, one piut 

Potatoes 


325 
320 


Oatmeal 


460 


Bread 


1280 


Sugar 


345 




66 


0.29 


0.22 


1.12 


3505 


IV. 

Beef, upper shoulder 

Ham .... 


10 
6 
3 
2 
16 
12 
9 
1 


0.09 
0.06 
0.03 

oioi' 

0.01 
0.05 


0.13 
0.13 
0.02 
0.11 
0.04 

*6.6i' 


'6.05 ' 
0.11 
0.38 
0.06 


800 
650 


Eggs, two 


135 


Butter 


450 


Milk, one pint 

Potatoes 


325 
240 


Flour 

Sugar 


825 
115 








59 


0.28 


0.44 


0.60 


3540 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



115 



Table XVII— (Continued). 

Standard Dietaries (Hutchison.) 

For a man at moderate muscular work. 



Food Materials 



V. 

Codfish. '..'.'.'.'. 

Butter 

Milk, one pint 

Beans 

Rice 

Potatoes 

Bread 

Sugar . . 



VI. 

Beef 

Mackerel, salt. 

Eggs, two 

Butter 

Cheese 

Milk, one pint 

Potatoes 

Rice 

Bread 

Sugar 



Amount 


Proteids 


Fats. 


Carbo- 
hydrates 


Ounces 

4 
14 

2 
16 

5 

2 
16 

9 

3 


Pounds 

0.03 
0.07 

o'oi' 

0.07 
0.01 
0.01 
0.04 


Pounds 

0.11 

0.04 
0.01 

o.oi' 


Pounds 

"om 

0.18 
0.10 
23 

0.28 
0.19 


71 


0.27 


0.28 


1.03 


8 
4 
3 

i 

16 
8 
2 
9 
1* 


0.08 
0.04 
0.03 

aos" 

0.04 
01 
0.01 
0.05 


0.10 
0.04 
0.02 
0.13 
02 
0.04 

* b^oi " 


'6.05* 

0.08 
0.10 
0.32 
09 


55 


0.28 


0.36 


0.64 



Fuel Value 



Calories 



510 
140 
450 
325 
505 
205 
420 
640 
345 



3540 



560 
230 
135 
565 
130 
325 
160 
205 
720 
175 



3205 



The caloric value of the different food-stuffs has been estimated 
by Atwater as follows: — 

Protein, fuel value, 4.1 calories per gram, or 1859 calories per 
pound. Fats, fuel value, 9.3 calories per gram, or 4218 calories per 
pound. Carbohydrates, fuel value, 4.1 calories per gram, or 1859 
calories per pound. 

To calculate the caloric value of any food, multiply the number 
of grammes of proteins by 4.1, the number of grammes of fat by 9.3. 
and the number of grammes of carbohydrates by 4.1. 

An ideal ration, suggested by Mrs. E. H. Eichards, consists of 
proteids, 106.80 grammes; fats, 57.97 grammes, and carbohydrates, 
389.80 grammes. On the other hand, Professor Chittenden, of Yale, 
maintained himself for nine months in an excellent physical condi- 
tion and in perfect nitrogenous equilibrium on a ration which con- 



116 TEXT-BOOK OF HYGIENE. 

d of about one-third the usual requirement of proteids, while the 
total daily fuel-value of his diet was only about one-half the usual 
requirement. He also experimented on a group of thirteen volun- 
teers from the Hospital Corps, United States Army. They ranged in 
age from 21 to 43 years, and were of different nationalities. These 
men did average work, engaging daily in gymnastics and other 
physical labor. Their daily menu, with slight variations, was about 
as follows : — 

Breakfast. — Boiled hominy, 150 grammes; milk, 125 grammes; 
sugar, 30 grammes; butter, 10 grammes; bread, 30 grammes; cof- 
fee, one cup. 

Dinner. — Split pea soup (thick), 200 grammes; bread, 75 
grammes; mashed potatoes, 100 grammes; pickles, 30 grammes; 
coffee, one cup; pie, 120 grammes. 

Supper. — Suet-pudding, 150 grammes; apple-sauce, 125 grammes; 
crackers, 25 grammes; tea, one cup. 

Total nitrogen, 7.412 grammes. Fuel value, 2000 calories. On 
this diet, poor in nitrogen, these men lived for six months, and at the 
end of the experiment were in a better physicial condition than when 
they commenced. 

A group of eight young college athletes were kept for five months 
on a diet equally poor in proteids, with the result that they gained in 
strength. 

"What has thus far been said about the ingredients of food and 
the ways they are used in the body may be briefly summarized in the 
following schematic manner (Atwater) : — 

Nutritive ingredients (or nutrients) of food. 
f Water. 



f Edible portion 

e.g., flesh of meat, 
volk and white of 
F °„°i?: i n ChaSed «HS«. -heat, flour, 

etc. 



Nutrients . . 



contains — 



Protein. 
Fats. 

Carbohydrates 
Mineral matters. 



Refuse. 
e.g., bones, entrails, shells, bran, etc. 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 117 

Uses of nu I lie it Is in the borfi/. 



All serve as fuel to 
yield energy in the 
forms of heat and 
muscular power. 



Protein Forms tissue 

e.g., white (albumen) of 
eggs, curd (casein) of 
milk, lean meat, gluten 
of wheat, etc. 

Fats Are stored as fat 

e.g., fat of meat, butter, 
olive oil, oils of corn and 
wheat, etc. 

Carbohydrates Are transformed into fatr 

e.g., sugar, starch, etc. 

Mineral matters (ash) . . Share in forming bone, assist in digestion, etc. 
e.g., phosphates of lime, 
potash, soda, etc. 

In addition to maintaining a proper proportion between the 
various alimentary principles, it is necessary to vary the articles of 
food themselves, otherwise they are liable to prove nauseating. The 
necessity of variety in the food, in order to preserve the appetite, 
is familiar to every one. 

If a man wished to live on beef alone he would be obliged to 
eat about 2 kilogrammes per day in order to get a sufficient amount 
of non-nitrogenous food. Of potatoes, in order to get enough nitro- 
genous food, he would have to eat 8 kilogrammes. No human stomach 
could prove equal to the task of digesting this excess of material. On 
the other hand, it is to be noted how perfect the combination of the 
various principles is in human milk. In cow's milk, which is nearest 
in composition to human milk, the non-nitrogenous principles are 
deficient. Hence, the important practical point that when ordering 
milk diet for a patient a small portion of carbonaceous food (bread, 
rice, or sugar) must be added if the standard of health shall be reached 
or maintained. 

Climate has probably very little influence upon the amount of 
food required by the individual. The actual quantity of food con- 
sumed varies little between various races or in different parts of the 
earth. It is true, however, that a larger proportion of fat is required 
in cold climates. That fatty articles of food readily undergo oxi- 
dation and furnish a large amount of animal heat is proven both by 
observation and experiment. 

The albuminoid proximate principles of the food, proteids, are 
represented by the nitrogenous constituents of organic tissues. These 
are the vitellin and albumin of eggs, albumin, fibrin, globulin, mvosin, 
sjTitonin, and other nitrogenized principles of flesh and blood; the 



118 TEXT-BOOK OF HYGIENE. 

casein of milk, the gluten, fibrin, and legumin of cereal and legumin- 
ous seeds and plants, gelatin, and chondrin. 

Fat constitutes an integral component of animal tissue, and is 
found in abundance as a constituent of nerve-tissue, marrow, and 
subcutaneous connective tissue. In food it is represented especially 
in the fatty tissue of meat, the yelk of eggs, butter, etc. 

The carbohydrates are represented especially by various products 
of the vegetable world, as sugar, starch, dextrin, etc. 

Water and various other inorganic proximate principles, chief 
among which are compounds of calcium, sodium, and potassium, 
are usually found in sufficient proportion in the other alimentary sub- 
stances. 

The food should be taken in appropriate quantities and properly 
prepared. A larger quantity than necessary may overtax the diges- 
tive organs and thus yield less than the required amount of nutritive 
material to the body. 

Physical exertion increases the consumption of fatty principles. 
Hence, as in the case of the athlete or prize-fighter in training, 
larger quantities of these principles are required to keep the nutrition 
of the body at the standard of health. During mental work, however, 
less carbohydrate material is consumed than during physical labor. 

The greater consumption of carbohydrates during muscular exer- 
cise is shown by the following table, which gives the amounts of 
carbon dioxide and nitrogen excreted by a man at rest and during 
labor : — 

Table XVIII. 





C0 2 Excreted. 


Nitrogen Excreted. 


* 

At rest 

At work 


912 grammes 
1284 " 


36.3 grammes. 
36.3 " 



In youth the processes of combustion (production of carbon 
dioxide) go on with greater rapidity than after adult life is reached. 
For this reason young persons rarely get fat, the fat-producing food 
being burnt up in the body by the greater metabolic activity of the 
young cell. Hence, fats and- carbohydrates should form a larger 
relative proportion in the diet of the young than in that of grown 
persons. 



FOODS OF ANIMAL ORIGIN. 119 

Low external temperature causes a greater and more rapid con- 
sumption of fat than high external temperature. During febrile 
conditions, however, the destruction of stored-up fat in the body — 
the wasting away — is one of the most notable phenomena; hence the 
importance of supplying fat and fat-producing food in chronic febrile 
diseases. 

"Der Mensch ist was er isst" said Ludwig Feuerbach. The pun- 
gency of the epigram is somewhat lost in the translation, which is, 
literally, "Man is what he eats/' The intimate relations of mental, 
moral, and physical conditions of health to the quality and quantity 
of food deserve the earnest attention of the educated physician and 
sanitarian. 

CLASSIFICATION OF FOODS. 

Foods and victuals are generally divided into foods proper and 
so-called accessory aliment. The classification is not exact, however, 
as the latter, which are commonly regarded as articles of luxury, may 
under certain circumstances become necessities, and hence should not 
be considered as forming a separate class. 

Foods are either of animal or vegetable origin. Those derived 
from animal sources are milk, the flesh of animals, birds, reptiles, 
and fish, and the eggs from the three last named. 

The foods derived from the vegetable kingdom comprise the 
seeds of various plants (cereals, legumes), roots, herbs, ripe fruits, 
the fleshy envelopes of various seeds (which may properly be classed 
with the fruits), and various fungi. 

There are also in common use a number of beverages, e.g., water, 
alcoholic liquors, alkaloid infusions (tea, coffee, cocoa), etc. 

In addition, a number of substances or compounds are in common 
use as condiments. Their function is either to render victuals more 
palatable, or to promote digestion and assimilation. Vinegar, must- 
ard, and common salt are familiar examples. 

FOODS OF ANIMAL ORIGIN. 

Milk. — Human milk is, so far as known, the one perfect food for 
man found in nature. It contains, in proper proportion, representa- 
tives of all the different classes of proximate principles necessary to 
nutrition. One hundred parts contain about 2.5 parts of proteids 

6 Gottheit, Freiheit und Unsterblichkeit von Standpunkt der Anthropolo- 
gic, p. 5. 



L20 TEXT-BOOK OF BYGIENE. 

(casein and albumin) ; 3.9 parts of fat (butter) ; 6.0 parts of sugar, 
and .5 of salts. The reaction of human milk is slightly alkaline; 
that of fresh cow's milk is neutral. 

In human milk there are 12.9 parts of solid matter to 87.1 of 
water, while in cow's milk the proportions are: Proteids, 4.0 per 
cent.: fats, 3.4 per cent.; sugar, 3.8 per cent; salts, 0.6 per cent., or 
11.8 total solids and 88.2 water. 7 

Of the solids in milk, cow's milk contains more proteids, while 
human milk is richer in fats and sugar. Hence, in using cow's 
milk as a substitute for human milk the proteids are diluted by the 
addition of water, and the non-nitrogenous components increased by 
adding sugar, and, under some circumstances, fat (cream). 

Goats' and asses' milk are sometimes used as substitutes for 
human milk, but they do not approach much nearer in composition to 
the latter than does cows' milk. 

On standing, the fatty constituent of milk, the cream, separates, 
and on account of its less specific gravity rises to the surface, where 
it forms a layer of varying thickness. 

After standing a longer interval the milk undergoes certain 
physical and chemical changes. Lactic acid is formed at the expense 
of part of the sugar of milk (a sort of fermentation taking place), 
and, acting upon the casein, produces coagulation. This is the so- 
called "bonny-clabber." When the fermentation continues, especially 
under a slightly elevated temperature, the solid portion becomes con- 
densed (curd), and a sweetish-acid, amber-colored liquid, the whey, 
separates. The curd, after further fermentation, under appropriate 
treatment, becomes converted into cheese. 

Whey is sometimes used alone or mixed with wine as an article 
of diet for the sick. 

Butter is made from the cream by prolonged agitation in a 
churn. The fat-globules adhere to each other and form a soft, 
unctuous mass, of a yellowish color, so 1 id at ordinary temperatures. 
After the butter is all removed in this way the balance of the cream 
remains in the churn as buttermilk. This is an article of considerable 
nutritive value, although its excess of acid renders it unsuitable as an 
article of diet in many cases. 

The specific gravity of fresh milk should not be below 1030. 
It should, however, be borne in mind that the richest milk is not 
always that which has the highest specific gravity. In fact, a sample 
of rich milk, containing a large proportion of cream, may show, when 

7 Average of a number of analyses. 



FOODS OF ANIMAL ORIGIN. 121 

tested with the lactometer, a lower specific gravity than a specimen of 
much poorer milk. Hence, the lactometer, although a useful instru- 
ment in guarding against excessive dilution of milk with water, is not 
a very trustworthy guide in determining the quality of the milk. 

Objections are often urged against the use of so-called "skim- 
milk," i.e., milk from which the cream has been removed. In some 
cities in this country the police, or representatives of the sanitary au- 
thorities, seize and confiscate all skim-milk found in possession of 
dealers. There appears to be no rational basis for the opinion held by 
many that skim-milk is not a proper and useful article of food. Before 
the lactic-acid fermentation has taken place it differs from fresh milk 
merely in the fatty and other matters removed in the cream. It con- 
tains nearly all of the proteids, sugar, and salts of whole milk, and 
may be used as an article of food with great advantage and entire 
safety. In certain disordered states it is of exceptional value as 
an article of diet. The sole objection of any weight to skim-milk is 
that it may be at times sold fraudulently as fresh milk. This is, how- 
ever, a question of little sanitary interest, but one principally of com- 
mercial ethics. 

Milk is frequently adulterated by the addition of water. More 
deleterious substances are rarely found. An excess of water gives the 
milk a bluish tinge and reduces its specific gravity. The addition of 
water may become especially dangerous by introducing the virus of 
some of the acute infectious diseases. Thus, the localized epidemics 
of typhoid fever have, in quite a number of instances, been traced to 
mixing the milk with water containing the germ of this disease. It 
should, however, be stated that milk which contains the germ of ty- 
phoid fever has not necessarily been adulterated by the addition of 
water. The typhoid bacillus may have been introduced with the water 
used in washing the can, and adhered to the sides of the latter. In 
filling the can with milk a good culture medium is supplied in which 
the typhoid bacillus flourishes. Diphtheria may also be communicated 
through the milk, by the latter becoming directly contaminated by 
the specific germs of this disease. 

It has long been a mooted question whether acute or chronic 
infectious diseases of the milk-giving animal may be communicated 
to persons using the milk of such animals. While there is little posi- 
tive knowledge upon the subject, it would seem prudent to avoid the 
use of milk from diseased animals, if possible, or to destroy any or- 
ganic virus the milk may contain by previously boiling the milk. 
After thorough boiling little fear need be entertained of communi- 



122 TEXT-BOOK OF HYGIENE. 

eating either acute or chronic infectious diseases through this medium. 
Demme and Uffelmann have reported cases which seem to demon- 
strate the possibility of tuberculous infection through the medium 
of the milk. Professor Bang, of Copenhagen, made a series of ex- 
periments and observations which led him to the conclusion that the 
milk of tuberculous cows and tuberculous women, in which there are 
no lesions in the mammary gland, only exceptionally contains the 
contagion. Professor Bang, at the same time, points out that the milk 
from tuberculous udders is extremely dangerous, and that the tubercle 
bacilli are to be found not only in the milk itself, but in the cream, 
buttermilk, and butter made from it; and that such milk is some- 
times infective by ingestion, even after exposure of 65° C. of heat, and 
by injection into the peritoneal cavity after exposure of 80° C. 

The infectiousness of the milk of cows suffering from splenic 
fever (milzbrand, anthrax) has been proven by Bollinger and Feser. 
Anthrax bacilli have been found in such milk by Chambrelent and 
Moussons. 

The agency of milk in the spread of scarlet fever is well recog- 
nized, but the manner in which the contagion gains access to the 
milk is not well understood. Several years ago an incident happened 
in England which seems to prove a close connection between this 
widespread and fatal disease and a disorder in the milk cattle. The 
evidence in support of this view is as follows : Mr. W. H. Power, of 
the English Local Government Board, was detailed to investigate cer- 
tain outbreaks of scarlet fever which seemed to have especial relation 
to the milk-supply from a particular dairy-farm. Upon inspection 
this dairy was found to be in excellent sanitary condition as regards 
cleanliness, water-supply, sewerage, etc., and for a time considerable 
difficulty was experienced in locating the cause of the outbreaks. 
Improbable as it may at first sight appear, it seems to have been in- 
contestably established that the epidemics of scarlatina were due to 
the use of milk obtained from cows attacked by a peculiar disease 
manifested by a vesicular eruption followed by ulceration of the udder. 
The chain of circumstances connecting the disease in the cows with 
the outbreak of scarlet fever in certain districts in London, supplied 
with milk from the diseased cows, was so strongly forged by the able 
investigator into whose hands the work had been committed by the 
authorities, that hardly a doubt can exist that the one disease owed 
its origin to the other. 

The pathological evidence furnished by Dr. Klein lends strong 
support to the view that the Hendon cow disease and scarlet fever are 



FOODS OF ANIMAL ORIGIN. 123 

intimately related to each other. A bacterial organism was found in 
the material from the ulcerated udders of the sick cows, which pre- 
sents similar characteristics to a micro-coccus found by the same ob- 
server in the blood of scarlet-fever patients. These results, however, 
require more extended investigations before they can be unreservedly 
accepted. 

The milk of cows fed upon the refuse of breweries and distilleries 
— "swill-milk" — is believed by many physicians to be unwholesome. 
If so, it is, probably, only by reason of the unfavorable hygienic con- 
ditions under which the animals are kept. If the stables are clean, 
dry, well-ventilated, and the animals receive plenty of fresh air and 
exercise, swill-fed cows should produce as nutritious milk as when they 
are fed upon different food. Much of the agitation against "swill- 
milk" is more prompted by political demagogism than by scientific 
knowledge. 

The milk of animals suffering from certain diseases is often dan- 
gerous to health. In some of the Western and Southern United 
States, cows are not infrequently attacked by an acute febrile disease 
called "the trembles," from one of the prominent symptoms. The 
milk of cows suffering from this disease produces severe gastrointes- 
tinal disorder, collapse, fever, etc., in the consumer. This disease, 
called "milk-sickness," is fatal in a pretty large proportion of 
cases. It is said that the flesh of animals with "the trembles" will, 
if eaten, produce similar dangerous effects. A late writer (Dr. Beach, 
of Ohio) estimates that 25 per cent, of the Western pioneers and 
their families died of this disease. 

For the ready determination of the quality of milk, instru- 
ments known as lactoscopes, lactometers, and creamometers are used. 
The lactoscope indicates the opacity of the milk, upon which the pro- 
portion of cream depends. One convenient modification of the lacto- 
scope is the little instrument termed the pioscope. This consists of a 
disk about 6 1 / 2 centimeters in diameter, with a slight depression in 
the centre. A little milk is placed in the depression and covered 
with a glass disk, clear in the centre and opaque around the border, 
which is divided into six divisions of different shades, varying from 
white to dark gray. The quality of the milk is marked upon the 
division whose color corresponds with that of the milk in the centre. 

A better, but still not very accurate indicator of the quality of the 
milk, is the creamometer. This consists of a cylindrical glass vessel 
with the upper half divided up into hundredths. The glass is filled 
up to the zero mark with milk, and allowed to stand until all the 



1:M 



TEXT-BOOK OF HYGIENE. 



cream has separated. The thickness of this layer is then read off on 
the scale. In Chevallier's instrument, 10 per cent, of cream is the 
minimum proportion that should be furnished by the milk. 

The specific gravity, which is a fair guide to the quality of the 
milk, with the reservations above mentioned, is measured by means 
of the lactometer or lactodensimeter. The specific gravity of good 
cows' milk should not be less than 1029. 




Fig. 10. — Chevallier's Creamometer. 



In order to prevent the rapid fermentation of milk various 
methods of preservation have been adopted. The addition of alkalies, 
or antiseptics, retards the lactic-acid fermentation, while the abstrac- 
tion of a portion of the water and addition of sugar (condensed milk) 
preserves it for an indefinite time. The mere addition of water re- 
stores it to nearly its original condition. 

Tyrotoxicon in Milk. — This substance, first found in poisonous 
cheese, and later in milk, ice-cream, custards, etc., is believed by Pro- 
fessor Vaughan to be the cause of true cholera infantum, and many of 
the clinical phenomena of this disease lend strong support to such a 
view. The conditions under which the poison is developed have not yet 
been sufficiently studied to enable correct conclusions to be drawn. 
Eecent studies, however, indicate that the summer diarrhea of infants 



FOODS OF ANIMAL ORIGIN. 125 

is caused by putrefactive bacteria in milk. The intimate relation be- 
tween milk containing large numbers of bacteria and diarrheal dis- 
eases in infants and children is becoming more and more apparent. 

Butter. — Butter is of especial value as food on account of the 
large amount of easily digestible fat which it contains. It is almost 
always used as accessory to other articles of food, to render them 
more palatable. When pure and fresh, it is one of the most delicious 
of foods. It soon undergoes the butyric-acid fermentation, however, 
becoming "rancid," as it is termed, when it is unfit for food. 

The great demand for butter and its consequent high price have 
led to its extensive sophistication. Butter is now very largely sub- 
stituted by an artificial substitute termed oleo-margarine, or butterine. 
This artificial butter is made from beef -suet by the following process : 
Fresh beef-fat is melted at as low a temperature as possible, never 
higher than 52° or 53° C. [126° to 128° P.]. All membrane and tissue 
are then removed, and the resulting clear fat is put into presses, where 
the stearine is extracted. The liquid fat, free from tissue, and with 
nearly all its stearine removed, is known as "oleo-margarine oil." 
The next step in the process is the "churning." The oil is a 1 - 
lowed to run into churns containing milk and a small quan- 
tity of coloring-material (annatto), where, by means of rapidly- 
revolving paddles, it is churned for about an hour. When this part 
of the process is complete, the substance is drawn off from the bottom 
of the churn into cracked ice. When cool it is taken from the ice, 
mixed with .a proper quantity of salt, and is then worked like butter 
and put into firkins for the market. It is also moulded into attrac- 
tive prints in imitation of dairy-butter. 8 When the materials from 
which oleo-margarine is made are sweet and clean, and when the pro- 
cess of manufacture is properly conducted, the resulting product is 
an entirely harmless article, and probably differs very little in nu- 
tritive value from butter itself. The only objection to oleo-margarine 
is a commercial one. It is so much like butter that dishonest dealers 
find it possible to substitute this product for the higher-priced natural 
product. 

Cheese. — The value of cheese as a food depends upon the large 
amount of proteids and fat which it contains. The rich varieties of 
cheese, such as Fromage de Brie and Eoquefort, contain on an average 
35 per cent, of fat and 27 per cent, of proteid compounds. Parmesan 
contains only about 18 per cent, of fat and nearly 40 per cent, of 

s Dr. W. K. Newton, Fifth Annual Report of the State Board of Health 
of New Jersey, 1881, p. 107. 



126 



TEXT-BOOK OF HYGIENE. 



proteids. while Edam and Cheshire cheese, which may be considered 
as Btanding about midway between the above, contain 30 per cent, of 
fat and nearly 28 per cent, of proteids. From these figures it ap- 
pears that cheese is one of the most nutritions aliments obtainable, 
but it cannot be eaten in large quantities at a time, as it is exceedingly 
liable to cause disturbances of the digestive organs. The constipating 
property of cheese is well known to the public. 

The relative value of different kinds of cheese in alimentary 
principles is given in the following table: — 

Table XIX. 



Kind of Cheese. 


Proteids 
(per cent.). 


Fats 
(per cent.). 


Sugar 
(per cent.). 


Salts 
(percent.). 


Cheshire 


27.68 


27.46 


5.89 


5.01 


Edam 


24.07 


30.26 


4.48 


4.91 


Holland 


29.48 


26.71 


2.27 


4.62 


Roquefort 


27.69 


33.44 


3.15 


5.35 


Neufchatel 


17.44 


40.80 


5.21 


2.05 


Parmesan 


41.19 


19.52 


1.18 


6.31 



Cheese is not often adulterated. The only articles used with 
success in its sophistication are lard and oleo-margarine, wmich are 
incorporated with the casein during the process of manufacture. It 
sometimes undergoes chemical changes which render it intensely 
poisonous when eaten. 

Professor V. C. Vaughan, of the University of Michigan, has 
ascertained that the substance causing the poisonous symptoms is a 
chemical compound termed by him tyrotoxicon. This same poison 
has also been found by Professor Vaughan and other chemists in 
ice-cream and fresh milk, which produced poisonous symptoms when 
consumed. The poison is supposed to be a ptomaine produced by the 
agency of a micro-organism, which has, however, not yet been isolated. 

Meat. — The flesh of mammals, reptiles, birds, fish, and inver- 
tebrate animals is used as food by man. Falck 9 has classified the 
varieties of animals which furnish food to the inhabitants of Europe. 
There are 47 varieties of the mammalian class, 105 of birds, 7 of 
amphibia, 110 of fish, and 58 of invertebrates. 



9 Das Fleiseh, Gemeinverstsendliches Handbuch der Wissenschaftlichen 
mid Praktischen Fleisehkunde. 



FOODS OF ANIMAL ORIGIN. 



127 



Meat is the most important source of proteicls in the food. In 
the more commonly used varieties of meat the proteids and fats consti- 
tute from 25 to 50 per cent, of the entire bulk, the proportion depend- 
ing largely upon the age of the animal and its bodily condition. The 
following table shows the influence of these two factors upon the rela- 
tive proportions of the fats and proteids in the meat : — 



Table XX. : 




Fats (per cent.). 



Moderately fat beef 
Lean beef . . . . 

Veal 

Very fat mutton 
Fat pork . . . . 
Lean pork . . . . 

Hare 

Lean chicken . . . 



5.19 
1.78 
T.41 
36.39 
3T.34 
6.81 
1.13 
1.42 



The flesh of animals, which is neutral in reaction immediately 
after death, soon becomes acid in consequence of the formation of 
lactic acid. The acid, acting upon the sarcolemma and the muscular 
fibre, renders it softer and more easily permeable by fluids when cook- 
ing, and more susceptible to the action of the gastric juice when the 
meat is taken into the stomach. 

Certain kinds of meat — mutton and venison, for example — are 
often kept so long before being eaten that a considerable degree of 
putrefaction has taken place when they are brought upon the table. 
The wisdom of this practice is questionable from a hygienic point of 
view. 

Meat is sometimes eaten raw, but it is usually first cooked. The 
methods of cooking in general use are boiling, frying, roasting, broil- 
ing, and baking. By either of these methods of cooking, when prop- 
erly carried out, the nutritious properties of the meat are preserved, 
and it is rendered digestible. The culinary art deserves the closest 
attention of students of hygiene. 

A number of soluble preparations of meat (beef -extract, beef- 
essence, beef-juice) are found in the market, and highly recommended 
as containing all the nutritious qualities of the meat from which they 



10 Abridged from Loebisch 
Heilkunde, vol. v, p. 340. 



article "Fleisch" in Realencyclopaedie d. ges. 



128 TEXT-BOOK OF HYGIENE. 

arc prepared. These, and similar products of domestic preparation 
(broths and teas), contain in reality very little nutritive material, but 
are of use almost solely as stimulants to the appetite and digestion. 
They have a place in the dietary of the sick but their nutritive value 
is small. 

On the other hand, a number of partly or wholly predigested 
(peptonized or pancreatized) preparations of meat are offered for sale, 
many of which have a high nutritive value. They cannot, however, 
be used as articles of diet except for a short time, or as a temporary 
succedaneum for meat in diseases attended with weakness or derange- 
ment of the digestive organs. Most of the predigested beef-prepara- 
tions on the market owe their effect to the large amounts of alcohol 
which they contain. 

Meat may be unfit for food from various causes. Thus the flesh 
of animals dying from certain diseases — splenic fever, pleuropneu- 
monia, tuberculosis in its advanced stages, cow- or sheep- pox — should 
not be used as food when it can be avoided. Cases are on record 
proving the poisonous character of meat from animals which suffered, 
at the time of death, from some of the above-mentioned diseases. 
The most important condition to be borne in mind is that certain 
parasites (trichina spiralis, echinococcus, cysticercus), which fre- 
quently infest the flesh of animals, especially hogs, not infre- 
quently give rise to serious or even fatal diseases in persons consum- 
ing such meat. Any meat containing these parasites or suspected 
of containing them, should therefore not be used as food unless pre- 
cautions be first taken to destroy the life of the parasite. 

Of the parasites mentioned the trichina spiralis is the most im- 
portant in this connection, as it frequently occurs in the flesh of hogs, 
rats, dogs, cats, and other carnivorous animals. Eats are said to be 
infested with the parasite more frequently than any other animals. 
The trichinae are found in two forms, one, the mature form, inhabiting 
the intestinal canal. The immature form, or muscle trichinae, are 
found in striped muscle, coiled into spirals and encysted in a fibrous 
capsule. They gain access to their host in the following manner: 
Flesh containing living trichinae is taken into the stomach, where the 
muscular tissue and the fibrous envelope are dissolved, and the in- 
closed worms set free. These mature in the intestinal canal, where 
sexual reproduction takes place, and the young embryos pass through 
the intestinal walls and other tissues until they become imbedded in 
striated muscle. Localized epidemics of trichinosis have been re- 
ported in this country and Europe, and in nearly every instance the 



FOODS OF ANIMAL ORIGIN. 129 

Source of the disease has been traced to the ingestion of uncooked 
pork. Meat known to be trichinous should not be used unless in times 
of great scarcity. It may, however, be rendered innocuous by thorough 
cooking. A temperature of G0° to 70° C. (140° to 160° F.) 
destroys the life of the parasite and renders the meat safe. On ac- 
count of the frequent occurrence of trichinae in pork, this meat should 
never be eaten unless thoroughly cooked. It has been ascertained 
that salted and smoked pork is not free from danger, as the parasites 
are not killed in the process of curing the meat. Hence, ham and 
sausage should not be eaten raw, as the danger from these articles is 
almost equally as great as from fresh pork. 

Cysticercus cellulosa, the transition form of one variety of tape- 
worm, and which is the parasite in measly pork, may also gain en- 
trance to the human body, and, failing to undergo development, cause 
very serious lesions of various organs and tissues. The frequency of 
tape-worm is evidence that pork is often thus diseased. 

The use of partially decayed meat or fish has often been the cause 
of serious or fatal illness. Sometimes the illness partakes of the 
character of septic infection. In these cases it is probable that the 
morbid process is due to the action of the organisms of putrefaction. 
In other cases the symptoms are widely different. These cases have 
been the source of much perplexity to physicians and toxicologists 
until very recently. Selmi, Husemann, Brouardel, Casali, and others 
have drawn attention to certain intensely poisonous chemical com- 
pounds found in decomposing flesh, and which have been named by 
Selmi ptomaines. While there is still much uncertainty concerning 
the nature of these compounds, it seems pretty well established that 
when flesh undergoes decomposition, in the absence of oxygen, certain 
unstable chemical combinations are formed which act as violent 
poisons. Selmi, followed by most toxicologists, believes these com- 
pounds to be alkaloids, analogous to the vegetable alkaloids, such as 
morphine, atropine, etc. Casali, on the other hand, disagrees with this 
opinion, and believes the ptomaines to be amido compounds. Huse- 
mann regards Casali's hypothesis as plausible, inasmuch as the for- 
mation of amido compounds in animal and vegetable bodies during 
decomposition is well established. 

The form of poisoning due to the organisms of putrefaction is 
not infrequent. An extensive outbreak of this nature occurred at 
Andelfingen, in Switzerland, in 1839. A musical festival was held, 
at which there were over 700 present. Out of these 444 were suddenly 
attacked by violent gastro-enteric and nervous symptoms. Ten of the 



130 TEXT-BOOK OF HYGIENE. 

patients died. The illness was traced to roast veal, which had been 
kept in a warm place for two days after roasting, and which was prob- 
alv in a state of partial decomposition. 

The class of cases which seem more probably due to the action 
of ptomaines or related poisons, have been frequently observed after 
eating sausages or canned meats. Sausage poisoning is not rarely ob- 
served in Germany. It has been ascertained that the internal portions 
of the sausage are the most poisonous. It is supposed that fhe 
ptomaines, which are formed in the absence of oxygen, are the active 
agents in the production of the train of symptoms. Poisoning by 
canned meat seems to be due to a similar poison. 

In July, 1885, an outbreak of disease, due to eating unwholesome 
beef, was caused at Momence, Illinois. Chemical examination of 
specimens of the meat showed the presence of an alkaloidal body 
which was believed to be a ptomaine, but its nature was not definitely 
determined. 

Fish, oysters, crabs, and lobsters frequently give rise to s}Tnp- 
toms of poisoning. In most of these cases the poisoning is probably 
due to partial decomposition, but it is a well-known fact that oysters 
and crabs are unfit for food at certain seasons. Some persons, how- 
ever, are subjects of a peculiar idiosyncrasy, in consequence of which 
shell-fish always produce certain unpleasant symptoms, among which 
nettle-rash and a choleraic attack are most prominent. 

That form of fish-poisoning known among the Spaniards in the 
West Indies as siguatera is, however, very grave. The mortality is 
large, and in many cases death succeeds rapidly upon the attack. The 
symptoms are as follow: Sometimes suddenly, sometimes preceded 
by dizziness and indistinct vision, great~ prostration and paralysis 
occur. Often death follows the onset of the symptoms in two and 
three hours. Exceptionally in less than twenty minutes. In most 
cases consciousness is totally lost ; in others it persists, with interrup- 
tions, until death. Sensation and the powers of speech and deglutition 
fail. The jaw muscles become paralyzed, the pulse is slowed, and the 
temperature diminished. There is sometimes vomiting, but no purg- 
ing. The secretion of the kidneys is also checked. Dr. Mc Sherry 
states 11 that he has seen all these symptoms produced by eating 
oysters, lobsters, and crabs, unseasonably. 

In Eussia a form of poisoning has often been observed which re- 
sults from eating salted sturgeon. In the fresh state these fish are 
perfectly wholesome, but when salted and eaten raw they produce a 

11 Health and How to Promote it, p. 143. 



FOODS OF ANIMAL ORIGIN. 131 

very fatal illness. The mortality is said to reach 50 per cent, of 
those attacked. No cases traceable to this cause have been observed 
in this country. Eecent investigations show that many cases of meat 
poisoning are caused by the bacillus of Gaertner, which belongs to the 
colon group of intestinal bacteria, while other cases are caused by a 
bacillus discovered by Van Ermengem in 1896 — the bacillus botulinus. 

It has been shown, beyond question, that the flesh of beeves suf- 
fering, when killed, from splenic fever, will produce this disease in 
the human subject. 

In 1874 an extensive and violent outbreak of an acute disease, 
characterized by vomiting and purging, fever and dizziness, occurred 
at Middleburg, in Holland. Three hundred and forty-nine persons 
were attacked, of whom 6 died. The outbreak was traced to eating 
liver-sausage (Leberwurst), in which the characteristic bacillus of 
splenic fever was found on microscopic examination. In July, 1877, 
an outbreak of choleraic disease, from eating carbuncular meat, oc- 
curred in the town of Wurzen. In the latter epidemic the bacillus of 
splenic fever (Bacillus anthracis) was found in the intestinal canal 
and in the blood of those attacked. 

In Detmold, in Germany, an outbreak of violent gastro-intestinal 
inflammation, accompanied by a high fever, occurred. Among the 
150 persons attacked 3 died. The disease was traced to eating the 
meat of a cow suffering, before death, from pleurisy (probably pleuro- 
pneumonia). 

In July, 1880, 72 persons who had eaten of certain beef and ham- 
sandwiches in Welbeck, England, were attacked by choleraic diar- 
rhea; 4 of the cases died. Inflammation of the lungs and small 
intestines was the most prominent pathological condition found post- 
mortem. The smaller blood-vessels of the kidneys were filled with 
finger-shaped bacilli, which, when cultivated and inoculated into 
guinea-pigs, rats, and white mice, produced similar pathological con- 
ditions. At Nottingham, England, in 1881, a number of persons were 
attacked by a similar train of symptoms after eating baked pork. One 
case terminated fatally out of the 15 attacked. It is uncertain whether 
the meat in these two instances was from diseased animals or whether 
it had undergone partial decomposition. The former is the more 
probable supposition, although the organisms found were neither those 
of splenic fever nor swine plague, but resembled those of symptomatic 
anthrax (black leg or black quarter). 

Whether the flesh of tuberculous animals can communicate tuber- 
culosis to the consumer is still an unsettled question. Foreign veterin- 



132 TEXT-BOOK OF HYGIENE. 

arians and hygienists who have studied the question incline to the view 
that there is danger of such transmission. At the International Sani- 
tary Congress of 1883, at Brussels, the subject was discussed, and M. 
Lvdtin, the chief veterinary surgeon of the Grand Duchy of Baden, 
submitted the following propositions, which were adopted by the Con- 
gress — 

1. That the flesh and viscera of tuberculous animals may be used 
as food, provided the disease is only commencing, the lesions extend- 
ing to but a small part of the body, the lymphatic glands being still 
healthy; provided the tubercle centers have not undergone softening, 
and provided the carcass is well nourished and the flesh presents the 
characters of meat of the first quality. 2. That the flesh of animals 
showing very pronounced tuberculous infection should be saturated 
with petroleum, and afterward burned under the direction of the 
police. 3. That the milk from cows affected with pulmonary phthisis, 
or suspected of having it, should not be consumed by man or other 
animals, and the sale of it should be strictly prohibited. 

The congress for the study of tuberculosis, which met in Paris 
in 1888, adopted resolutions of a more decided character against the 
use of meat and milk from tuberculous animals. Eecent investiga- 
tions fully substantiate the opinions expressed at these congresses. 

Certain animals can devour with impunity substances which are 
intensely poisonous to human beings. The flesh of the animals may 
be impregnated with these poisons, and cause serious and fatal illness 
in persons partaking of it. In this way may, perhaps, be explained 
the cases of poisoning sometimes following the eating of partridges 
and other birds. 

The prevention of disease from tainted meat is one of the most 
important problems of public hygiene. Food animals should be in- 
spected by qualified inspectors before slaughtering, to exclude animals 
suffering from diseases that would vitiate the meat. When the meat 
is exposed for sale upon the dealer's stall it should be again inspected, 
and all found unfit for use as food confiscated and destroyed. Meat, 
in which the presence of trichinas or other parasites is suspected, 
should be examined microscopically. 12 The recent disclosures in con- 
nection with the scandalous neglect of sanitary precautions in the 

12 The prevention of the diseases of animals by National and State au- 
thorities is one of the most logical and thorough-going means of preventing 
disease from unwholesome meat. The American Public Health Association has 
for some years devoted considerable attention to the investigation of the dis- 
eases of animals and means for their prevention. The Department of the In- 
terior of the National Government has likewise made the diseases of cattle 
and hogs a subject of study and published some valuable reports thereon. 



FOODS OF VEGETABLE ORIGIN. 133 

packing-houses in Chicago emphasize the necessity of great vigilance 
in the inspection of meats at these establishments. However, these 
disclosures, unpleasant as they were at the time, led to prompt eradi- 
cation of the existing evils. 

Eggs. — Although eggs contain a large amount of the proteid and 
fatty alimentary principles, their value as food has probably been 
greatly overrated. The savory taste and ready digestibility of eggs 
have, however, rendered them a popular article of food. For obvious 
reasons, the eggs. of the common barnyard fowl are most frequently 
used, those of ducks and geese being far inferior in flavor to the first 
named, and being likewise less easily obtained. 

The method of cooking eggs is generally supposed to have con- 
siderable influence upon their digestibility. According to Dr. Beau- 
mont's experiments made on Alexis St. Martin, raw eggs are digested 
in one and a half to two hours, fresh-roasted in two hours and fifteen 
minutes, soft-boiled or poached in three hours, and hard-boiled or 
fried in three and a half hours. These experiments are, however, of 
very little value as a basis for general conclusions. It is probable 
that a hard-boiledr egg is quite as easily digested in the healthy stom- 
ach as a raw one, if care be taken to masticate it well and eat bread 
with it, so that it is introduced into the stomach in a finely-divided 
state. 

Eggs readily undergo putrefaction, when sulphuretted hydrogen 
is formed in them in large quantities. When this has taken place they 
are manifestly unfit to be used as food. 

FOODS OF VEGETABLE ORIGIN. 

Bread. — The various cereal grains, when ground into flour, are 
used in making bread. The flours of wheat, rye, barley, buckwheat, 
and Indian corn are almost exclusively used in bread-making. The 
bran or cortical portion of grain contains a larger percentage of pro- 
teid principles than the white internal portion; hence, flours made 
from the whole grain (bran flour, Graham flour) if finely ground are 
more nutritious than the white flours. The latter are, however, more 
digestible, and hence furnish a larger proportion of nutriment, be- 
cause the principles contained in white flours are absorbed and as- 
similated to a greater degree. 

Good bread should be light, porous, and well baked. The light- 
ness and porosity are due to carbon-dioxide gas imprisoned in cavities 
of the dough during the process of bread-making. By adding j^east 



134 TEXT-BOOK OF HYGIENE. 

to the dough a fermentation is caused in the latter, in consequence of 
which a portion of the starch is converted into sugar, and then into 
alcohol and carbon dioxide. During the process of mixing the dough 
the entire mass becomes permeated by the gas, which, on heating, ex- 
pands and leaves the numerous large and small cavities throughout 
the loaf which indicate properly made bread. 

Instead of yeast some persons use leaven, which is simply a por- 
tion of fermenting dough saved from a previous baking. A small 
quantity of this added to a mass of dough starts up the fermentation 
in a similar manner to that of yeast. 

The production of carbon dioxide by fermentation in the dough 
goes on at the expense of part of the starch. It has been proposed, 
therefore, to supply the carbon dioxide from without, thus saving 
the entire amount of the carbohydrates present in the flour. This 
is accomplished in two ways — first, by the use of some alkaline car- 
bonate or bicarbonate (bicarbonate of sodium, carbonate of ammo- 
nium), the carbon dioxide being set free on the application of heat; 
or, secondly, by forcing gas, previously prepared, into the dough by 
means of machinery. 

Flour is not infrequently adulterated with chalk, gypsum, pipe- 
clay, and similar articles. These are easily detected by adding a min- 
eral acid, which produces effervescence when it comes in contact with 
the alkaline carbonate used as an adulterant. Potato- and bean- meals 
are also used as adulterants of the higher grades of flour. Bakers 
often mix alum with inferior grades of flour. This imparts a greater 
degree of whiteness to the bread, and, in addition, enables it to retain 
a large proportion of water, thereby increasing the weight of the 
loaf. 

Formerly diseased grain (ergotized rye) often caused outbreaks 
of disease when the flour made from the diseased grain was used in 
bread-making. At present time such accidents rarely occur. In some 
parts of Italy it is said that an endemic disease — pellagra — is caused 
by the consumption of diseased Indian corn. The evidence in favor 
of this view, is, however, not unquestioned. 

Potatoes and rice are often used with satisfaction as substitutes 
for bread. They both contain a large proportion of carbohydrates. 
Indian corn (hominy) and oatmeal are likewise wholesome and nutri- 
tious foods of this class. 

The leguminous seeds (beans, peas, lentils) furnish a food con- 
taining a large percentage of proteids. According to the analyses of 



FOODS OF VEGETABLE ORIGIN. 



135 



Koenig 13 the average composition of the most frequently used legumes 
in the dried condition is as follows: — 

Table XXI. 





Beans. 


Peas. 


Lentils. 


Ground-nuts 14 


Water, per cent. . . . 
Solids, per cent. . . . 


13.6 

86.4 


14.3 

85.7 


12.5 

87.5 


6.5 
93.5 


Proteids, per cent. . . 

Fats 

Carbohydrates, per cent. 
Cellulose, per cent. . . 
Ash 


23.1 
2.3 

53.6 
3.9 
3.5 


22.6 
U 

53.2 
5.5 

2.7 


24.8 

1.9 
54.7) 

3.6} 

2.5 


28.2 
46.4 

15.7 

3.2 



Beans, peas, and lentils are often added to other articles of food 
with advantage. An important article of food for armies has been 
made of various legumes ground into flour and mixed with fat, dried 
and powdered meat, salt, and spice. This constitutes the so-called 
"Erbswurst," or pea-sausage, which formed such an important part of 
the dietary of the German army in the Franco-German war of 1871. 
Bean- and pea- meals are also used sometimes as additions to other 
flours in bread-making. The dried leguminous fruits cannot be used 
as regular articles of diet, however, as they soon pall upon the taste, 
and produce indigestion, nausea, and other intestinal derangements. 

Green Vegetables. — The plants usually classed together as 
"vegetables," the products of the market-garden or truck-farm, com- 
prise cabbages, turnips, parsnips, onions, beets, carrots, tomatoes, let- 
tuce, green peas and beans, and similar articles. They all contain 
a large proportion of water, a variable proportion of sugar, and a 
small percentage of proteid principles. Much of their palatability and 
digestibility depends upon the methods by which they are prepared for 
the table. All garden vegetables should be used soon after being 
gathered, as they rapidly undergo decomposition, and are liable to 
produce derangements of the digestive organs if used under these 
conditions. 

Fruits and Nuts. — These generally contain large quantities of 
sugar and fats. They form agreeable additions to other articles of 
diet, but are insufficient to sustain life. The use of fruits usually 



13 Die Menschlichen Nahrungs und Genussmittel, ii. p. 288. 

14 The American pea-nut, the fruit or nut of Arachis hypogcea. 



136 TEXT-BOOK OF HYGIENE. 

produces copious intestinal evacuations, and they are, therefore, espe- 
cially to be recommended to persons of sedentary occupations, in whom 
torpidity of the bowels is so frequently present. 

Condiments. — Various aromatic herbs and seeds are used as addi- 
tions to other articles of food, to increase their sapidity and to pro- 
mote a larger flow of saliva and gastric juice, and so assist digestion. 
Mustard, pepper, allspice, and vinegar are the principal condiments. 
Within certain limits they are not injurious, but the tendency in the 
use of all stimulants is to exceed a healthful limit. Condiments, as 
well as other stimulants, should be used in moderation. 



COOKING. 

Much more attention than is generally given should be paid by 
physicians to the culinary art. The manner in which food is cooked 
has no little influence upon its digestibility. There can be no question 
that the extreme prevalence of functional indigestion in this country 
is almost exclusively dependent upon bad cooking. 

The various methods of cooking are boiling, frying, roasting, 
broiling, and baking. By either of these methods food can be cooked 
so as to be palatable as well as digestible; on the other hand, the 
choicest article can be utterly spoiled and rendered unfit to be taken 
into the human stomach. It depends, therefore, not so much upon 
the method of cooking, as upon the knowledge and art of the cook. 

Boiling. — Meats of all kinds are rendered tender and digestible 
by boiling. In order to retain the flavor of meat, the water should be 
boiling when the meat is put into it. By the heat of the boiling water 
the albumin on the outside of the meat is coagulated and the juices 
and flavor are retained within. After a few minutes the temperature 
of the water should be reduced to 71° to 77° C. (160° to 170° F.), and 
maintained at that height until the meat is tender. By this process 
a much more savory piece of beef, mutton, or fowl can be obtained 
than where the meat is put into cold water and thus graduaHy heated. 
The latter method is, however, the proper one to be followed when 
good soup or broth is desired. 

In boiling vegetables, as much care is necessary as in boiling 
meat or fish. Potatoes and rice should be steamed, rather than 
boiled. 

The difficulty of obtaining a good cup of coffee, especially in the 
northern part of the United States, illustrates the prevailing ignor- 
ance upon one of the simplest points in the art of cooking. Coffee 



COOKING. 137 

should never be served in the form of a decoction ; that is to say, it 
should never be boiled. Properly made it is an infusion, like tea, 
which no one ever thinks of boiling. The difference between an in- 
fusion (especially if made by percolation) and a decoction of coffee 
can only be appreciated by those who have enjoyed the one and en- 
dured the other. 

Frying. — Frying, if properly done, is really nothing less nor 
more than boiling in oil or fluid fat of some kind. Olive-oil is pre- 
ferable, but is not essential ; butter, beef-drippings, lard, or probably 
cotton-seed oil may be substituted for it without disadvantage. The 
principle of frying depends upon the fact that the temperature of oil 
can be raised to such a height as to produce instant coagulation on 
the surface of meat, fish, or other objects immersed in it while hot; 
this film of coagulated albumin imprisons the juices and flavors of 
the meat or fish, and prevents the fat entering and soaking the fibers 
with grease. Small fish or birds, properly fried, are justly regarded 
as delicacies by connoisseurs, but the process of saturating these ob- 
jects with fat while gradually heating them produces a dish that 
is anything rather than grateful to the palate, or conducive to good 
digestion. 

Roasting. — The fame of the "roast beef of Old England" has 
passed into song, but, at the present day, beef and other meats are 
rarely roasted, either in this country or abroad. As Sir Henry 
Thompson well expresses it, 15 "the joint, which formerly turned in 
a current of fresh air before a well-made fire, is now half stifled in 
a close atmosphere of its own vapors, very much to the destruction of 
the characteristic flavor of a roast." It is probable that the old method 
of roasting before an open fire produced not only the most savory, 
but likewise the most nutritious and digestible, meat. It is to be 
much regretted that the process has fallen so greatly into disuse. 

Broiling and Baking. — These methods of cooking are modifica- 
tions of the process of roasting. Meats or fish, carefully broiled or 
baked, preserve their natural juices and flavors to a great extent, and 
retain their digestibility and nutritions properties. Of all methods 
of cooking these are probably the best known and most satisfactorily 
applied in this country. 16 

15 Food and Feeding, p. 45. London, 1880. 

10 Every one interested in the proper application of the principles of cook- 
ery should study the Lomb prize essay of the American Public Health Asso- 
ciation, by Mary Hinman Abel, upon "Practical, Sanitary, and Economic Cook- 
ins:." This little book can be obtained of Dr. I. A. Watson, Secretary, Concord. 
N. H. ; price, 25 cents. See. also, an essay on "The Art of Cooking," by Edward 
Atkinson, LL.D., in Popular Science Monthly, November, 1889. 



[38 TEXTBOOK OF HYGIENE. 

ALIMENTARY BEVERAGES. 

The alimentary beverages may be divided into two classes, — 
those depending for their effect upon the alcohol they contain, and 
those -whose active principles reside in certain alkaloids. They are 
used chiefly as digestive and nervous stimulants. 

BEVERAGES CONTAINING ALCOHOL. 

The physiological action of alcohol has been pretty fully worked 
out by Binz and his pupils, and by other experimenters. From these 
researches, it appears that the first effect of taking alcohol, sufficiently 
diluted, into the stomach is to increase the flow of the saliva and gas- 
tric juice. This effect is probably reflex, and results from a stimulation 
of nerve terminations in the stomach. The alcohol is rapidly absorbed, 
and is carried in the blood, without undergoing chemical change, to the 
nervous centres, lungs, and tissues generally. In the brain the alcohol 
probably enters into combination with the nervous tissue, modifying 
the normal activity of the various centres, either increasing the 
activity, if the alcohol is in small quantity (stimulating effect), or 
diminishing it if in larger quantity (depressing effect), or entirely 
suspending the activity of the centres, if in sufficiently large quantity 
(paralyzing effect). 

Alcohol stimulates the vasodilator nerves, causing dilatation of 
the smaller vessels ; in consequence of this the blood is largely sent to 
the periphery of the body; the blood-pressure diminishes, and heat- 
radiation is increased. At the same time a portion of the alcohol is 
used up in the lungs in the production of animal heat, thus econom- 
izing the expenditure of fats and proteid, and acting as a true re- 
spiratory food. Alcohol does not contribute nutritive material to 
the body; it only permits that which is stored up to be saved for 
other uses, by furnishing easily-oxidizable (combustible) material for 
carrying on the respiratory process, and supplying animal heat. 

During the use of alcohol the excretion of urea is diminished. 
This shows that waste of tissue is retarded in the body. 

Regarding the statement of some authorities that alcohol does not 
undergo any change in the body, but is excreted unchanged, Binz 
asserts 17 that alcohol appears in the urine only when exceptionally 
large quantities have been taken, and then in very small proportion. 
It is not excreted by the lungs, the peculiar odor of the breath being 

17 Realencyclopsedie d. ges. Heilk., Bd. I, p. 183. 



BEVERAGES CONTAINING ALCOHOL. 139 

due not to the alcohol, but to the volatile aromatic ether, which is 
oxidized with greater difficulty, and so escapes unchanged. 

While alcohol produces subjectively an agreeable sensation of 
warmth in the stomach and on the surface of the body, the bodily 
temperature is not raised. The subjective sensation is due to the 
dilatation of the blood-vessels and the sudden hyperemia of those 
parts. 

During fevers and other exhausting diseases, alcohol is invaluable 
to prevent waste of tissue and sustain the strength. It does not act 
merely as a stimulant to the circulation and nervous system, but, as 
above pointed out, saves the more stable compounds by furnishing a 
readily oxidizable respiratory food. 

When taken in small doses by healthy persons, alcohol dimin- 
ishes the temperature by increasing heat-radiation. W 7 hen large quan- 
tities are taken, the bodily temperature is reduced by diminishing 
heat production, as well as by increased radiation. This is shown 
in the condition known as dead-drunkenness, in which the tempera- 
ture is sometimes depressed as much as 20° F. below the normal. 
Cases in which the temperature sank to 75°, 78.8°, and 83° F. have 
been reported, with recovery in all cases. 

In discussing the physiologic effect of alcohol Dr. Hall 18 makes 
use of what he regards as the "deadly parallel" between food and 
alcohol : — 

Food. Alcohol. 

1. A certain quantity will produce 1. A certain quantity will produce 
a certain effect at first, and the same a certain effect at first, but it requires 
quantity will always produce the more and more to produce the same 
same effect in the healthy body. effect when the drug is used habit- 
ually. 

2. The habitual use of food never 2. When used habitually it is likely 
induces an uncontrollable desire for to induce an uncontrollable desire for 
it, in ever increasing amounts. more, in ever increasing amounts. 

3. After its habitual use a sudden 3. After its habitual use a sudden 
total abstinence never causes any de- total abstinence is likely to cause a 
rangement of the central nervous sys- serious derangement of the central 
tern. nervous system. 

4. Foods are oxidized slowly in the 4. Alcohol is oxidized rapidly in the 
body. body. 

5. Foods, being useful, are stored 5. Alcohol, not being useful, is not 
in the body. stored in the body. 

6. Foods are the products of con- 6. Alcohol is a product of decom- 
structive activity of protoplasm in position of food in the presence of a 
the presence of abundant oxygen. scarcity of oxygen. 



The Journal of the American Medical Association, vol. xlviii, No. 5, 1907. 



140 TEXT-BOOK OF HYGIENE. 

Food. Alcohol. 

7. Foods (except meats) are formed 7. Alcohol is formed in nature only 
in nature for nourishment of living as an excretion. It is, therefore, in 
organisms and are, therefore, inher- common with all excretions, inher- 
ently wholesome. ently poisonous. 

8. The regular ingestion of food is 8. The regular ingestion of alcohol 
beneticial to the healthy body, but is deleterious to the healthy body, 
may be deleterious to the sick. but may be beneficial to the sick 

(through its drug action). 

0. The use of food is followed by 9. The use of alcohol, in common 
no reaction. with narcotics in general, is followed 

by a reaction. 

10. The use of food is followed by 10. The use of alcohol is followed 
an increased activity of the muscle by a decrease in the activity of the 
cells and brain cells. muscle cells and brain cells. 

11. The use of food is followed by 11. The use of alcohol is followed 
an increase in the excretion of C0 2 . by a decrease in the excretion of C0 2 . 

12. The use of food may be followed 12. The use of alcohol is usually 
by accumulation of fat, notwithstand- followed by an accumulation of fat 
ing increased activity. through decreased activity. 

13. The use of food is followed by 13. The use of alcohol may be fol- 
a rise in body temperature. lowed by a fall in body temperature. 

14. The use of food strengthens 14. The use of alcohol weakens and 
and steadies the muscles. unsteadies the muscles. 

15. The use of food makes the 15. The use of alcohol makes the 
brain more active and accurate. brain less active and accurate. 

The constant use of alcohol produces in all the organs an excess 
of connective tissue, followed by fatty degeneration and the condition 
known as cirrhosis. The organs most frequently affected are the 
stomach, liver, and kidneys. Serious pathological alterations also 
occur in the circulatory, respiratory, and nervous systems. 

Alcohol is not necessary to persons in good health. Probably 
most persons, regardless of their state of health, do better without it. 
Its habitual use in the form of strong liquors is to be unreservedly 
condemned. The lighter wines and malt liquors, if obtained pure, 
may be consumed in moderate quantities without ill effects. Even 
in these forms, however, the use of alcohol should be discouraged or, 
perhaps, prohibited in the young. 

Neither in hot nor in cold climates is alcohol necessary to the 
preservation of health, and its moderate use even produces more in- 
jury than benefit. The Polar voyager and the East Indian mer- 
chant are alike better off without alcohol than with it. 

It has long been a prevalent belief that the use of alcohol enables 
persons to withstand fatigue better than where no alcohol is used. 



BEVERAGES CONTAINING ALCOHOL. 



141 



A large amount of concurrent testimony absolutely negatives this 
belief. 19 

The predisposition to many diseases is greatly increased by the 
habitual use of alcohol. Sun-stroke, the acute infectious diseases, and 
many local organic affections attack, by preference, the intemperate. 
A recent collective investigation by the British Medical Association 
brought out the fact that croupous pneumonia is vastly more fatal 
among the intemperate than among those who abstain from the use 
of alcoholic liquors. 

A further investigation by Baer has shown that the average ex- 
pectation of life among users and dealers in alcoholic liquors is very 
much shortened. The following table gives a comparative view of the 
expectation of life in those who abstained from and those who used 
alcohol : — 

Table XXII. 

EXPECTATION OF LIFE. 



Age. 


Abstainers. 


Alcohol Users. 


At 25 


32.08 
25.92 
19.92 
14.45 
9.62 


years. 

a 

a 
u 
u 


26.23 years 
20.01 " 


"35 


"45 


15.19 " 


"55 


11.16 " 


"65 


8.04 " 



Table XXIII shows the influence of alcohol upon the mortality 
from various diseases : — 



Table XXIII. 





General Male Popu- 
lation (per cent.). 


Alcohol Venders 
(per cent.). 


Brain disease 

Tuberculosis 

Pneumonia and pleuritis .... 

Heart disease 

Kidney disease 

Suicide 

Cancer 

Old age . 


11.77 
30.36 
9.63 
1.46 
1.40 
2.99 
2.49 
22.49 


14.43 

36.57 
11.44 
3.29 
2.11 
4.02 
3.70 
7.05 



See Parkes' Hygiene, 6th ed., vol. i, pp. 315-327. 



142 TEXT-BOOK OF HYGIENE. 

Alcohol as a beverage is consumed in the various forms of 
spirits, wines, and fermented liquors. The varieties of spirits most 
Frequently used are brandy, whisky, rum, and gin. They are all 
procured by distillation. 

Brandy is distilled from fermented grape-juice, and has a char- 
acteristic aromatic flavor. "When pure and mellowed with age it is 
the most grateful to the palate of all distilled spirits. 

Whisky is distilled from barley, rye, oats, corn, or potatoes. 
Each of these has a peculiar flavor, depending upon the particular 
volatile ether formed during the distillation. Eye-, barley-, and corn- 
whiskies are almost exclusively used in this country. 

Rum is distilled from molasses, and is a favorite ingredient in 
hot punches. It is often used with milk, eggs, and sugar, in the prepa- 
ration of eggnog, a highly nutritious, stimulating drink, which is 
often prescribed with great benefit in acute and chronic wasting dis- 
eases. 

Gin is an ardent distilled spirit, flavored with oil of juniper. 
It has a widely-spread popular reputation as a cure for kidney dis- 
eases, but is probably oftener responsible for the production of these 
diseases than for their cure. 

All of the above-mentioned liquors contain from 40 to 60 per 
cent, of alcohol, and should always be diluted before being taken into 
the stomach, in order to prevent the local irritant effects of the alco- 
hol upon the gastric mucous membrane. 

Wine is the product of the alcoholic fermentation of the sac- 
charine constituents of fruits. Wine is usually derived from the 
grape, though other fruits may also furnish it. The stronger wines 
(sherry, port, maderia) contain from 16 to 25 per cent, of alcohol. 
The lighter wines (hock, red and white Bordeaux and Burgundy 
wines, champagnes) contain from 6 to 15 per cent, of alcohol. Some 
also contain considerable free carbonic acid (sparkling w r ines), of 
which the champagnes are types. The red and white Bordeaux and 
Bhine w r ines are probably the least objectionable of these beverages 
for habitual use. They contain sufficient alcohol to be lightly stim- 
ulant, have a pleasant acid flavor, and are least likely to produce 
the bad effects which usually follow in the wake of the habitual use 
of the stronger wines or ardent spirits. 

Preference should be given to the wines of domestic manufacture, 
on account of the great probability of adulteration of the favorite 
brands of foreign wines. Many of the California, Virginia, New York, 



BEVERAGES CONTAINING ALCOHOL. 143 

and Ohio wines compare very favorably in flavor with those imported 
from abroad. The more reasonable cost of these domestic wines is 
also a point in their favor. 

Cider is the fermented juice of apples. It frequently produces 
unpleasant gastric and intestinal disturbances when drunk, on ac- 
count of the large quantity of malic acid contained in it. Although 
it is usually ranked as a "temperance drink," it is quite capable of 
causing intoxication when consumed in large quantities. 

Beer is the fermented extract of barley, mixed with a decoction 
of hops and boiled. It should be prepared only of malt, hops, yeast, 
and water, and should contain from 3 to 4 per cent, of alcohol, 5 to 
6 per cent, of extract of malt and hops, 2 to 4 per cent, of lactic and 
acetic acids, and from 1 / 4 to 1 / 2 per cent, of carbonic acid. This ideal 
is, however, rarely attained in the article sold by the liquor dealer. 
Numerous adulterations are practiced on the unsuspecting con- 
sumer. The hops are frequently substituted by aloes, calamus, and 
ginger, or by the more deleterious picric acid or picrotoxin. The 
rich brown color, sweetness, body, and creamy foam are produced by 
caramel and glycerin. The more expensive barley-malt is substituted 
by starch and rice, or grape-sugar and molasses. 

Ale, porter, and brown-stout are merely varieties of beer — some 
containing more sugar, others more extractive matter. 

Beer and its correlatives have considerable dietetic value, owing 
not merely to the alcohol they contain, but largely to the sugar and 
acids entering into their composition. When used to excess they often 
cause a considerable accumulation of fat. 

Kumys is the national beverage of the nomadic tribes of Tar- 
tary. It consists of the milk of mares which has undergone fermen- 
tation, partly lactic and partly alcoholic in character. Eecently it 
has been introduced into Europe and also into this country, where 
it is made of cows' milk. It is a palatable, .nutritious stimulant, and 
is often very useful as a dietetic article in disease. Kumys may be 
prepared according to the following formula : To one pint of fresh 
milk add one tablespoonful of sugar and 1 / 6 cake of compressed yeast. 
Put in bottle with patent stopper, place in warm room or near the 
stove for 6 to 12 hours, then cool on ice and serve. Kumys has proved 
a very valuable agent in the treatment of gastro-intestinal diseases. 

Kefyr is a product of the fermentation of milk which bears some 
resemblance to kumys. The following table (Table XXIV) gives a 
comparative view of the composition of true kumys, the same prepared 
from cows' milk, and kefyr : — 



144 



TEXT-BOOK OF HYGIENE. 
Table XXIV. 





True Kumys 


Cows 1 Milk Kumys 


Kefyr 




(percent.). 


(percent.). 


(percent.) 


Proteids 


2.20 


2.35 


3.12 


Fats 


2.12 


2.07 


1.95 


Sugar 


1.53 


1.81 


1.62 


Lactic acid 


0.90 


0.40 


0.83 


Alcohol 


1.72 


1.90 


2.10 


co^ 


0.85 


0.80 


0.92 



As bearing on the question of intemperance, it may be well to 
mention that many patent medicines which are largely consumed 
by the laity for their supposed curative effect owe their virtues to the 
large amounts of alcohol which they contain. The following is a list 
of the more popular tonics, analyzed principally by the Massachu- 
setts State Board of Health: — 



Table XXV. 

Alcohol, 
Per cent. 

Liebig Company's Cocoa Beef Tonic 23.2 

Schenck's Seaweed Tonic, "entirely harmless" 19.5 

Atwood's Quinine Tonic Bitters 29.0 

Boker's Stomach Bitters 42.6 

Burdock Blood Bitters 25.2 

Copp's White Mountain Bitters, "not an alcoholic beverage" . . 6.0 

(It should be noticed that this "tonic" contains more alcohol 
than the strongest beer.) 

Drake's Plantation. Bitters 33.2 

Green's Nervura 17.2 

Hoofland's German Bitters, "entirely vegetable and free from 

alcoholic stimulant" 25.6 

Hostetter's Stomach Bitters 44.3 

Kauf mann's Sulphur Bitters, "contains no alcohol" 20.5 

(As a matter of fact no sulphur was found in this prepara- 
tion.) 

Paine's Celery Compound 21.0 

Walker's Vinegar Bitters, "contains no spirit" 6.1 

Warner's Safe Tonic Bitters 35.7 

Ayer's Sarsaparilla 26.2 

Hood's Sarsaparilla 18.8 

Dana's Sarsaparilla 13.5 

Peruna 28.0 

Warner's Safe Cure 15.60 

Kilmer's Swamp Root 10.90 

Toneoo Stomach Bitters 35.50 

Angostura Bitters 50.17 



THE ALKALOIDAL BEVERAGES. 145 

The dose recommended on the labels is from a teaspoonful to a 
wineglassful from one to four times a day, "increased as needed." 

The pure food law recently enacted by our national government 
requires the amount of alcohol in a medicinal preparation to be plainly 
stated on the label. Whether this will remove the existing evil of sell- 
ing alcohol under the guise of medicine remains to be seen. 

THE ALKALOIDAL BEVERAGES. 

The virtues of the alkaloidal beverages depend upon certain 
alkaloids which differ very little in their chemical composition or 
physiological effects, and upon certain volatile aromatic constituents 
of the various articles used. The principal articles employed in the 
preparation of these beverages are coffee, tea, chocolate, mate, and 
coca. It is estimated that 500,000,000 people drink coffee, 100,000,000 
tea, 50,000,000 chocolate, 15,000,000 mate or Paraguay tea, and 
10.000,000 coca. All of these are active nervous stimulants and re- 
tarders of tissue-waste. They are all liable to produce serious func- 
tional disturbances of the nervous, digestive, and circulatory systems 
if used to excess. Anaemia, digestive derangements, constipation, 
pale, sallow complexion, los's of appetite, disturbed sleep, nervous 
headaches, and neuralgias are the most marked of these effects. 

On the other hand, when taken in moderate quantities, the alka- 
loidal beverages enable the consumer to withstand cold, fatigue, and 
hunger; they promptly remove the sensation of hunger, and diffuse 
a glow of exhilaration throughout the body. 

Coffee. — Coffee is the ripe fruit (seed) of the Caffea Arabica, 
a native of Arabia and Eastern Africa, but now cultivated in other 
tropical regions of the world. The fruit consists of two flat-convex 
beans, the flat surfaces of which are apposed to each other. These 
are enclosed in a fibrous envelope which is sometimes used as a cheap 
substitute for the coffee-bean. 

The beverage, coffee, is an infusion of the roasted and ground 
bean in hot water. Its virtues depend upon the alkaloid, caffein, and 
an aromatic oil. The latter, being volatile, is driven off by long- 
continued heat. Hence boiled coffee lacks the grateful aroma of that 
which is made by simply infusing the ground bean in hot water. 

The great demand for coffee and its comparatively high price 
have caused it to be extensively adulterated and substituted by other 
natural and artificial products. Artificial coffee-beans have been made 
of clay, dough, or extract of chicory, colored to imitate the natural 

10 



146 TEXTBOOK OF HYGIENE. 

bean. The fraud is easily detected by placing the beans in water, 
when the artificial product soon falls to pieces, while the natural 
beans undergo no change of shape or consistence. 

Ground coffee as found in the stores is usually adulterated. The 
materials used for sophistication are: The grounds of coffee previ- 
ously used, the roasted root of chicory, acorns, rye or barley, carrots, 
sun-flower seeds, caramel, and a number of articles of similar value, 
generally harmless. 

Tea. — The plants which furnish the tea-leaves are natives of 
China, Indo-China, and Japan. The tea-leaves contain a crystalline 
alkaloid, thein, identical in composition and properties with caffein. 
The various sorts of tea found in the market (green and black teas, 
etc.) differ only in the relative proportion of tannin and thein con- 
tained in each. The aromatic principle also varies somewhat in the 
different sorts. 

Tea is adulterated to quite as great an extent as coffee, the leaves 
of various plants bearing more or less resemblance to tea-leaves' 
being added to the latter. Much of the tea found in the market is 
colored artificially with Prussian blue and iron oxide. These addi- 
tions are harmless, as they are not soluble in water. 

Chocolate. — Cocoa, from which chocolate is derived, is widely 
different in composition from tea and coffee. In addition to its ac- 
tive principle, theobromin, which is identical with caffein, it contains 
nearly 50 per cent, of fat, which, renders it an article of high nutri- 
tive value. 

Mate, or Paraguay tea, guarana, and coca are used to a 
considerable extent in some parts of South America as substitutes 
for coffee and tea. Their composition is not well known, but their 
effects are believed to depend upon alkaloidal principles similar to 
caffein and thein. 

TOBACCO. 

Closely connected with the subjects treated in this chapter are 
the effects of the constant use of tobacco upon the human system. 
The depressing effects of tobacco, due principally to the nicotine, upon 
the nervous and digestive systems have long been recognized. Ee- 
cently, however, it has been found that very serious symptoms are 
produced upon the sense of vision by the constant or excessive use of 
tobacco. A special form of amaurosis, termed tobacco amaurosis, has 
been frequently noticed since attention was first called to it by 
Mackenzie. 



ADULTERATIONS OF FOODS. 147 



ADULTERATIONS OF FOODS. 

The adulteration of food-products has received considerable 
attention of late, no more, however, than the seriousness of the sub- 
ject demands. There is hardly a food-product which is not sophisti- 
cated by the unscrupulous manufacturer, and, while most of the 
adulterants are harmless, many are injurious to health. The follow- 
ing list from Battershall gives an adequate idea of the common adul- 
terations. As to the uncommon adulterants, they include such pal- 
atable substances as sawdust, horseliver, oak-bark, colored earths, fac- 
tory sweepings, brick-dust, and numerous others which the ingenuity 
of the manufacturer suggests, and which baffle all efforts at detection, 
owing to their uncommonness. The regular list, then, includes: — 

„.,*■.» f Starch, 

Bakers' chemicals < .-. 

Bread and flour f Other meals, 

«■ Alum. 

r Water, 
Butter < Coloring matter, 

( Oleomargarine and other fats. 

Canned foods { ^ etallic P oisons ' 

I Preservatives, 

f Lard, 

Oleomargarine, 

Cottonseed oil, 

Metallic salts. 



Cheese 



( Sugar, 

Cocoa and chocolate -j Starch, 

1 Flour. 
r Chickory, 
' Peas, 



Coffee -1 Rye, 

I Corn, 

[ Coloring matter. 

f Starch-sugar, 

I Starch, 

, ,. Artificial essences, 

Confectionery 1 -r> ■ • j. 

J Poisonous pigments, 

j Terra alba, 

[ Plaster-of-Paris. 

j Glucose syrup, 

I Cane-sugar. 

{ Artificial glucose, 

I Bitters, 
Malt liquors j godium bicarbonate> 



Honey 



Salt. 



148 TEXT-BOOK OF HYGIENE. 

(Water, 
Removal of fat, 
Preservatives. 
{Flour, 
Turmeric, 
Cayenne pepper. 

Olive oil I Cottonseed oil, 

I Other oils. 

Pepper Various ground meals. 

Pickles Salts of copper. 

{Pepper dust, 
Starch, 
Flour. 
Water, 
Fusel-oil, 
Aromatic ether, 
Burnt sugar. 

Sugar ■ Starch-sugar. 

f Exhausted tea-leaves, 
Foreign leaves, 
Indigo, 

Tea ■{ Prussian blue, 

Gypsum, 

Soapstone, 

Sand. 

TT . f Water, 

Vine ^ ar \ Sulphuric acid. 

f Water, 
me j Coal-tar and vegetable colors, 



Spirits 



Factitious imitations. 



Of 61 samples of milk purchased of milk-dealers in the city of 
Wilmington and examined by the Delaware State Board of Health 
Laboratory, 39 contained formalin, 12 were skimmed, 3 were watered, 
5 were skimmed and watered, and 2 were suspicions. 

The superficial observer will probably conclude that adulteration 
is accidental and irregular; that it depends entirely on the honesty 
and business integrity of the individual manufacturer. This is far 
from being the case. Sophistication is an economic factor in the 
struggle for trade. Cheaper products are demanded by the poor, 
and cheaper products are supplied; but as the only way to cheapen 
them is to sophisticate, adulteration is practiced as a bona fide busi- 
ness measure. As a result, we have fraud reduced to a system; 
fraud not regulated by conscience or principles; fraud from which 
the otherwise honest man does not shrink, but, nevertheless, fraud 



• ADULTERATIONS OF FOODS. 149 

which robs the poor man of the money he earns by the sweat of his 
brow. 

This fact has been clearly brought out by the Senate Committee 
appointed to investigate the extent and nature of adulteration of 
foods (Senate Report, Vol. 3, No. 516). "The adulteration of pre- 
pared or manufactured foods," says the committee, "is very exten- 
sively practiced, and in many cases to the great discredit of our man- 
ufacturers. It is only fair to say, however, that a large proportion 
of the American manufacturers who are engaged in adulterating 
food-products do so in order to meet competition, and it is the ex- 
pression of those gentlemen to say: 'We would be glad to get out of 
the business of adulterating. We would like to quit putting this stuff 
in our coffee, and would be willing to brand our syrups for what they 
are, but our competitors get a trade advantage which we cannot sur- 
render/ " 

In a recent report of the Illinois State Food Commission (1899- 
1900) we find the following table of adulterations detected during the 
year : — 

Table XXVI. 

Number Number 

Article of Food. Analyzed. Adulterated. 

Baking powder 44 44 

Butter 49 36 

Catsup 47 45 

Cider (apple) 3 1 

Cider (orange) 1 1 

Coffee 15 

Condensed milk (bulk) 4 1 

Condensed milk (cans) 22 4 

Cream of tartar 11 2 

Honey 22 9 

Jellies, Jams, etc 13 9 

Lemon extracts 34 27 

Milk 29 5 

Olive oil 25 13 

Sugar (granulated) 1 1 

Vanilla extract 26 20 

Vinegar . ... 360 192 

Total 712 412 

The recently enacted pure food law will remedy the evil of mis- 
branding so far as interstate commerce goes, but will not prevent 
adulteration of foods and food-products within the limits of any 
single State. State legislation will be required to meet these condi- 
tions in each State. 



150 TEXT-BOOK OF HYGIENE. 



THE EXAMINATION OF FOOD. 

It would be manifestly inadvisable to attempt to detail the 
methods for the determination of the purity and healthfulness of the 
many articles of food that make up the daily dietaries of the people 
at large; but since occasions are constantly arising when it is desir- 
able to know something of the condition of certain food-stuffs which 
are used by practically every one, and which are especially liable to 
sophistication or adulteration, the following notes are, therefore, 
added as being within the scope of the chapter: — 

Milk. — Good milk should be ivory- white m color, opaque, of 
neutral or slightly-alkaline reaction, and should have no sediment nor 
any unusual taste or odor. The specific gravity should be 1029 or 
above; the proportion of cream, from 10 to 40 per cent, by volume; 
the fats, 3 per cent, or more, and the total solids 12.5 per cent, or 
more. The number of bacteria should not exceed 500,000 per cubic 
centimetre. 

The color is enriched by a high percentage of cream, but too 
rich a color or one with a reddish or yellowish tint may indicate the 
addition of annatto. A poor color indicates that the milk is deficient 
in fat, and may be due to skimming or watering, or both, but a pecu- 
liar blue color is sometimes produced by the growth of a certain fungus 
in the milk. The lessening of fat also tends to make the milk trans- 
lucent and less opaque. 

An acid reaction, unless very slight, indicates "souring" of the 
milk or the addition of some preservative, such as salicylic or boric 
acid; while a strongly-alkaline reaction points to the addition of some 
substance like chalk, sodium carbonate, etc., to increase the specific 
gravity. Such addition is verified by a high percentage of total solids 
and by the effervescence of the latter upon the addition of a drop or 
two of hydrochloric acid. 

The specific gravity is determined by means of the lactometer, 
in using which corrections must be made for the temperature if the 
latter varies much from 60° F., the standard. The specific gravity 
is slightly raised by skimming the milk, since the cream is lighter 
than the whole milk, and, theoretically, a very high percentage of 
cream tends to lower the specific gravity; but, in reality, a milk rich 
in cream is also rich in other solids that keep the specific gravity high 
or, at least, normal. 

The percentage of cream is determined by the creamometer, 



THE EXAMINATION OF FOOD. 151 

which should be covered and in which the milk should stand for eight 
or ten hours. 

The principal sophistications of milk are by watering, skimming, 
the addition of solids ta increase the specific gravity or to act as pre- 
servatives or to mask "souring/' and the addition of annatto and the 
like to enrich the color. Watering is indicated by a low specific 
gravity and by a low percentage of cream and of total solids. Skim- 
ming is indicated by a low percentage of cream and poor color, though 
the latter may be disguised by the addition of annatto, etc. The spe- 
cific gravity will be very slightly raised by the skimming, but if the 
milk has been both skimmed and watered the density will be lowered. 

To Determine the Percentage of Total Solids. — Weigh a small 
evaporating dish, preferably platinum. Add 5 or 10 c. c. of milk, and 
weigh the dish and milk to get the weight of milk. Evaporate to 
dryness over a water-bath, completing the drying in a water-oven 
until there is no further loss of weight. Weigh the dish and contents 
(total solids) ; subtract the weight of dish and divide by the weight of 
milk. The result is the percentage of total solids. 

To Determine the Percentage of Ash. — Ignite the total solids 
over the naked flame until all black specks have disappeared. Cool 
and weigh. Divide the weight of 'ash by weight of milk. The result 
is the percentage of ash. 

To Determine the Percentage of Fats. — Proceed as above with 
10 c. c. of milk and evaporate till the residue is a tenacious pulp. 
Extinguish the flame, fill the dish half-full of ether, and stir and pound 
the residue thoroughly with a glass rod ; filter through a small filter- 
paper, reserving the filtrate ; add more ether to the residue, stir as 
before and filter, repeating the process three times, or till the residue 
is perfectly white. Wash filter-paper well with ether, and evaporate 
all the ether to dryness. Weigh the residue (the fat) and divide by 
the weight of milk. Eesult : percentage of fat. The fat can be more 
conveniently determined by the use of the Babcock tester. This is a 
centrifugal machine holding two or more graduated bottles especially 
made for this purpose. The test is performed as follows : Measure 17.6 
c. c. of milk and an equal quantity of strong sulphuric acid (sp. gr. 
1.82) and pour into the bottle. Mix by shaking gently until curd dis- 
solves. Place in centrifuge and revolve at 1000 revolutions per min- 
ute for five minutes. Fill the bottles to the highest graduation with 
hot water and whirl for one minute longer. Read on the scale the 
space occupied by the column of fat which rises to the top. The lower 
margin of this column indicates the percentage of fat. 



152 TEXT-BOOK OF HYGIENE. 

Test for Annatto. — A percentage of cream considerably lower 
than color of milk would indicate justifies the suspicion that some 
coloring matter has been used. This is generally annatto. Coagulate 
one ounce of milk with a few drops of acetic acid, and heat ; strain and 
press out excess of liquid from curd. Triturate the curd in a mortar 
or dish with ether. Decant the ether and add to it 10 c. c. of a 1- 
per-cent. solution of caustic soda. Shake and allow to separate ; pour 
off the upper layer into a porcelain dish. Put in two small discs or 
strips of filter-paper. Evaporate gently; annatto will dye the discs 
an orange or buff color. Moisten one disc with dilute sodium carbon- 
ate to fix the color. Touch the other disc with a drop of stannous 
chloride ; annatto will give a rich pink color. This test is sensitive to 
1 part of annatto in 1000 of milk, and with milk in any condition. 

Detection of Cane-sugar in Milk and Cream. — Mix 15 c. c. of 
milk or cream with .1 gram resorcin and 1 c. c. cone, hydrochloric acid 
and heat to boiling. In presence of cane-sugar a fine red color is pro- 
duced, while pure milk turns brownish; 0.2 per cent, can thus be de- 
tected. Levulose gives the same reaction, but glucose does not. 

Test for Boric Acid. — In igniting the total solids, boric acid, or 
boron, gives a greenish tinge to flame. Place in a porcelain dish one 
drop of milk, two drops of strong hydrochloric acid, and two of sat- 
urated tincture of turmeric. Dry on a water-bath, remove as soon as 
dry, cool and add one drop of ammonia on a glass rod. A slaty-blue 
color, changing to green, is given if borax is present. This test will 
show y i0 oo grain of borax. Less will give the green color, but not the 
blue. 

Formaldehyde. — The milk is diluted with an equal volume of 
water. Sulphuric acid containing a trace of ferric chloride is added 
so that it forms a layer beneath the milk. Under these conditions, 
milk, in the absence of formaldehyde, gives a slight greenish tinge at 
the juncture of the two liquids, while a violet ring is formed when 
formaldehyde is present even in so small a quantity as 1 part in 200,- 
000 of milk. 

Sodium Carbonate. — Ten c. c. of milk are mixed with an equal 
volume of alcohol and a few drops of a 1-per-cent. solution of rosolic 
acid added. Pure milk shows merely a brownish-yellow color, but in 
the presence of sodium carbonate a more or less marked rose-red ap- 
pears. This test is made more delicate by using a comparison cylin- 
der containing the same amount of milk known to be pure. 

Butter. — Good butter should have a good taste, odor, and color; 
it should not be rancid, and should not contain too much salt, nor 



THE EXAMINATION OF FOOD. 153 

should it have any added coloring matter. The average composition 
should be about as follows: Fat, 82 per cent.; casein, 2 per cent, 
(not over 3 per cent.) ; ash or salts, 2 per cent.; water, 13 per cent.; 
milk-sugar, 1 per cent. Butter-fat is a compound of a glycerine with 
certain fatty acids, some of them volatile and soluble in hot water, 
others non-volatile and insoluble in hot water. 

Oleo-margarine consists of ordinary animal (or vegetable) fats 
melted, strained, cooled with ice, worked up with milk, colored, and 
salted. These' fats are usually beef or mutton, lard or cotton-seed, 
palm- or cocoa-nut- oil. If care and cleanliness are observed in the 
manufacture, oleo-margarine is not harmful or innutritions, but it 
should not be sold as butter. 

Fraud is to be detected by observing the difference in composition 
and properties of the fats. The following table, from Kenwood's 
"Hygienic Laboratory," will show the characteristic difference in the 
fats : — 

Butter-fat. Beef-fat. 

1. The specific gravity is very Is never above 904.5. 
rarely below 910, never below 909.8. 

2. The soluble, volatile fatty acids Barely more than y 2 per cent.; 
average between 6 and 7 per cent, never above % per cent. 

never below 4.5 per cent. 

3. The insoluble fatty acids form Generally about 95 per cent, 
about 88 per cent, of the total weight 

of butter-fat. 

4. The melting-point of the fat Barely, if ever, above 82° F. 
varies from 86° to 94° F.; is usually 

from 88° to 90° F. 

5. Is readily and completely soluble Less so, and leaves a residue, 
in ether. 

6. Under the microscope pure but- The contours of the small oil-glob- 
ter consists of a collection of small ules are less distinct, and the larger 
oil-globules with an occasional large ones are more numerous and irregular 
one. No crystals, except when the in size. Crystals of the non-volatile 
fat has been melted. acids are often seen. 

To Determine the Specific Gravity. — Melt a quantity of the but- 
ter in a beaker on a water-bath at about 150° F. After a time, when 
the fat is perfectly clear and transparent, carefully decant from the 
lower stratum of water, curd and salt on to a fine filter; collect the 
filtrate and pour into a specific-gravity bottle, which has been previ- 
ously weighed, both when empty and when filled with water at 100° F. 
See that the bottle is exactly full of the fat; wipe clean and weigh 
when the temperature is as near 100° F. as possible^ because solidifica- 



154 TEXTBOOK OV HYGIENE. 

tion soon begins at this temperature. Subtract the weight of the 
bottle, divide by the weight of the water, and multiply by 1000. The 
result is the specific gravity. 

To Find the Melting-point. — Pour a little melted fat into a small 
test-tube (2 ff x 1 / 4 ' f ). Partly fill two beakers of unequal size with 
cold water; place the test-tube in the smaller (taking care to allow 
no water to mix with the fat), and the smaller in the larger, and 
gently heat the outer beaker. Suspend a thermometer in the smaller, 
near the test-tube, and note the temperature when the fat begins to 
melt. This is the melting-point. 

To Determine the Percentage of Insoluble (Non-volatile) Fatty 
Acids. — To 5 grammes of butter-fat add 50 c. c. of alcohol contain- 
ing 2 grammes of caustic potash (KHO) and boil gently for fifteen 
or twenty minutes to saponify the fat. Dissolve the soaps thus formed 
in 150 to 200 c. c. of water and decompose with about 25 c. c. of dilute 
hydrochloric acid. The separated fatty acids are collected upon a 
weighed filter-paper, washed with 2 litres of boiling water, dried at 
95° to 98° C, and then weighed. The weight of these insoluble fatty 
acids should not be over 90 per cent, of the weight of the butter-fat. 

Flour and Bread. — Wheat-flour should be almost but not per- 
fectly white, also smooth and free from grit ; it should have no moldy 
or unpleasant odor, and, unless made by the new process, should be 
cohesive when lightly compressed in the hand. There should be no 
signs of parasites or fungi under the microscope. The proportion of 
gluten should be more than 8 per cent. ; of water, less than 18 per 
cent., and of ash, less than 2 per cent. 

To Determine the Percentage of ^Water and Ash. — In a weighed 
platinum (or porcelain) dish place about 50 grammes of flour, weigh 
and dry over a water-bath for an hour or so ; then complete the evap- 
oration in a water-oven until there is no further loss of weight; 
weigh, subtract this weight less the weight of the dish from the orig- 
inal weight of the flour. The result is the percentage of water. Then 
ignite the dried flour in the dish and incinerate till there are no 
longer any black particles and only the ash remains ; cool, weigh, and 
divide by the original weight of the flour. The result is the per- 
centage of ash. 

To Determine the Percentage of Gluten. — By means of a glass 
rod, mix a weighed quantity of flour with a little distilled water into 
a stiff dough ; then repeatedly wash away the starch and soluble con- 
stituents, kneading the dough with the rod or fingers and continuing 
until the wash-water comes away clear ; the gluten and a small amount 



THE EXAMINATION OF FOOD. 155 

of fat and salts remain. Spread out on a weighed dish or crucible-lid, 
dry in a water-oven, and weigh. Divide by the original weight of the 
flour. The result is the approximate percentage of gluten. The 
gluten should pull out in long threads, otherwise it is poor. 

An excess of water impairs the keeping-quality and lessens the 
amount of nutriment in the flour. An excess of ash indicates the 
addition of mineral substances. A deficiency of gluten indicates that 
the flour is not pure wheat-flour. Parasites and fungi especially affect 
or live in old or damp and inferior flour. 

To Test for Mineral Substances. — Shake a little flour in a test- 
tube with some chloroform, and allow it to stand for a few mo- 
ments. The flour floats and any mineral matter sinks to the bottom, 
when it can be removed with a pipette and examined under a micro- 
scope. 

Wheat-bread should be fairly dry, light, and spongy; clean and 
nearly white; of pleasant taste; not sodden, acid, or musty; no 
parasites or moldiness. It should contain no flour other than wheat; 
•but little, if any, alum; no copper sulphate; and should not yield 
over 3 per cent, of ash. 

Test for Alum. — Add 5 c. c. of a 5-per-cent. tincture of logwood 
and 5 c. c. of a 15-per-cent. solution of ammonium carbonate to 25 
c. c. of water ; soak a crumb of the bread in this for a few minutes ; 
drain and gently dry. Alum is indicated by a violet or lavender 
color, its absence by a dirty-brown color on drying. 

Test for Copper Sulphate. — Draw a glass rod dipped in a solution 
of potassium ferrocyanide across a cut slice of the bread; copper is 
indicated by a streak of brownish-red color. 

Test for Ergot in Flour or Bread. — Add liquor potassse; a dis- 
tinct, herring-like odor (due to propylamine) is appreciable if ergot 
be present. 

An excess of water, an unnatural whiteness, and a low percentage 
of ash in bread indicate the addition of rice. Potatoes give an in- 
creased percentage of water and an alkaline ash. 



QUESTIONS TO CHAPTER III. 



FOOD. 



What is a food? What reasons have we for stating that the proximate 
food principles must be combined in definite proportions to maintain a normal 
degree of health? What are the alimentary principles necessary to man's 
existence? Why do we need water? What are the functions of the salts in 
our foods? Is existence possible without a sufficient supply of nitrogenous 
food? What is the relation of starch to fat as oxidizable food? 

Are the proteid tissues of the body derived solely from the nitrogenous 
foods? What are the sources of the body -fat? What tissues are mostly con- 
sumed during work? 

What is the relation between the proximate food principles, and what 
amount of each is necessary in the standard daily diet of a man at rest? At 
moderate labor? At hard work? About what is the relation of nitrogenous 
to non-nitrogenous food? Of nitrogen to carbon? Is a standard diet neces- ' 
sarily an expensive one? How may it be selected? What is a calorie? 

Why is a variety in the kind of food necessary? Why may not a man 
live on nitrogenous foods, like meat, alone? W T hy not on non-nitrogenous 
food, like potatoes? 

Has climate much influence upon the amount of food needed? Has it 
upon the kind of food? What kind of food is especially beneficial for a labor- 
ing man in cold weather? Where do we find the proteid principles of food? 
Where the fatty? Where the carbohydrates? The salts? Why should only 
a moderate amount of food be taken, and why should it be properly prepared? 
What are some of the factors that increase the consumption of carbonaceous 
foods? Does increased physical labor increase the demand for nitrogenous 
foods? Which requires the most carbonaceous food, physical or mental labor? 
What maladies especially require fat-producing foods? Has the food that a 
man eats anything to do with his moral character? 

How may we classify food? Name some of animal origin. From the 
vegetable kingdom. What is the function of condiments? Of stimulants? 

Why is milk so nearly a perfect food? What is the average composition 
of cows' milk? What is the difference between human milk and cows' milk? 
What other substitutes are sometimes used for human milk? 

What is cream? What changes take place in milk upon standing for 
some time? To what are these changes due? What is made from the curd? 
Has whey, or butter-milk, any food value? 

■What should be the specific gravity of milk? How is it determined? 
What may lower the specific gravity? What may raise it? Has "skim-milk" 
a food value? W 7 hat is the objection to its sale? 

(156) 



QUESTIONS TO CHAPTER III. 157 

How is milk frequently adulterated? How may this be detected? Why 
is the addition of water dangerous? How else might the milk become in- 
fected? 

May infectious diseases be transmitted from the cow to man through 
the milk? How may this danger of infection be avoided? What diseases are 
especially likely to be thus conveyed by the milk? Give an account of the 
"Hendon cow disease." May the milk of animals suffering from certain febrile 
diseases be dangerous to health? Is the milk of cows fed on distillery or 
brewery refuse necessarily unwholesome? 

How may the quality of a milk be determined? What is a lactoscope? 
What is a creamometer? What should be the minimum percentage of cream? 
How may the rapid fermentation of milk be prevented? What is tyrotoxicon, 
and to what is it due? 

What is butter? What is its food value, and why? What change does 
it undergo in becoming "rancid"? How is it often sophisticated? W T hat is 
oleo-margarine or butterine? How is it made? Is it unwholesome, and is 
there any objection to its use if sold under its proper name? Upon what 
does the value of cheese depend? Is it nutritious? Why cannot large quan- 
tities be eaten at a time? 

What are the richest kinds of cheese? Is cheese often adulterated? How 
may cheese be made more digestible? What dangerous change may it undergo, 
and to what is this due? 

Why is meat such an important article of food ? What is the percentage 
of proteids and fats in the meats commonly used? Upon what does the varia- 
tion between these two principles depend? Should meat be cooked and eaten 
immediately after death? Should it be kept too long after death before being 
used? Why should meat be always cooked? What are the common methods 
of cooking? Are beef-extracts really nutritious? Are partially or wholly pre- 
digested preparations of meat nutritious? What is the objection to their 
continued use? 

What conditions may render meat unfit for food? How may the various 
parasites in meat be destroyed? What animals are apt to be infested with 
trichinae? In what two forms are the trichinae found in animals? How do 
they gain access to the muscles? May salted or smoked meat contain living 
trichinae? Of what parasite is the Cysticercus cellulosa a transition form? 

What may be the result of using partially-decomposed meat or fish? To 
what are the serious results due? How are the ptomaines produced? What 
is their probable chemical nature ? What peculiar idiosyncrasy have some 
people regarding shell-fish? "What infectious diseases may be transmitted to 
human beings by the consumption of infected meat? When and by whom 
should meat be inspected? 

Why are eggs so highly valued for food ? In which form are eggs most 
digestible? Why do eggs undergo putrefaction so readily? 

What cereals are used in making bread? What part of the grain con- 
tains the greater proportion of proteids? Is all the gluten to be found in the 



158 TEXT-BOOK OF HYGIENE. 

bran? Which flours are most nutritious and which most digestible? What 
are some of the characteristics of good bread? To what is the porosity due, 
and how is it produced? How may the loss of starch by fermentation be 
avoided? How is Hour often adulterated? Why is alum added to flour? What 
disease of grain may be harmful to the health of the users? 

What is the chief constituent of potatoes and rice? In what principle 
are the leguminous foods especially rich? Wherein is the chief value of green 
vegetables? Why are fruits and nuts valuable as articles of diet? What rule 
should be observed regarding the use of condiments? 

Why should physicians know considerable about cooking? What are 
the various methods of cooking? What is the effect of boiling upon meats? 
What points are to be observed in the boiling of meat? In the making of 
soups, etc.? What valuable principle is lost if vegetables are boiled too long? 
What is the secret in making good coffee? What is frying? How should it 
be done? How should meats be roasted? Why are broiling and baking gen- 
erally satisfactory processes? 

Into what two classes may alimentary beverages be divided? For what 
are those of the second class used? What is the physiological effect and action 
of alcohol upon the nerve-centres? Upon the circulation? Is it changed before 
absorption? Does it nourish the body? Does it supply heat? Does it raise 
the body- temperature? What effect has it on heat-production and heat-radia- 
tion? On tissue waste? How is it excreted? What effect have small amounts 
of alcohol upon digestion? What pathological changes are brought about by 
the constant use of alcohol? Is it necessary or beneficial to persons in good 
health? Why is it so valuable in fevers and wasting diseases? Does it enable 
persons to withstand fatigue? To what diseases is the predisposition increased 
by the habitual use of alcohol ? What effect has it upon the expectation of 
life and upon the mortality from various diseases? If used habitually, what 
forms should be chosen? What is the difference between spirits, wines, and 
malt liquors? What is brandy? From what is whisky made? How much 
alcohol do the various spirits contain, and what rule should be observed re- 
garding their use? What percentage of alcohol do the various wines contain? 
Which are the least objectionable for habitual use? What can be said regard- 
ing the domestic wines? To what disturbances may cider give rise, and why? 
From what articles alone should beer be made? How much alcohol should it 
contain? With what substances is it often sophisticated? Have beer, ale, 
etc., a dietetic value, and why? What may be the result when beer is used 
to excess? What are kumys and kefyr? Why are they valuable in sickness? 
How much alcohol does each contain? Upon what do the virtues of the 
alkaloidal beverage depend? What are the principal articles employed in their 
preparation? What is the physiological action of all these substances? What 
are some of the effects if they are used to excess? What is their effect when 
used in moderation? May they be used as substitutes for alcohol? 

What is coffee, and what alkaloid does it contain? What else does it 
contain that gives value to the beverage? How is coffee adulterated, and how 
may fraud be detected? What is tea, and what alkaloid does it contain? How 
may it be adulterated? Why is cocoa of greater food value than tea or 



QUESTIONS TO CHAPTER III. 159 

coffee? What is its active principle, and what is its relation to thein and 
caffein? What is the difference between cocoa and chocolate? What are the 
effects of tobacco upon the human system, and to what are they due? 

What are some of the characteristics of good milk? What may affect its 
color? Its reaction? Its specific gravity? How is it usually sophisticated or 
adulterated? How is the percentage of total solids determined? Of fats? 
What would a high percentage of ash indicate? Give a test for annatto. For 
boric acid. For formaldehyde. 

What are the characteristics of good butter? What is the difference 
between it and oleo-margarine and similar compounds? What two kinds of 
fatty acids does butter-fat contain? W T hat are some of the distinctions be- 
tween butter-fat and beef-tea or mutton-fat? How is the specific gravity of 
butter-fat determined? The melting-point? The percentage of insoluble fatty 
acids? 

What are some of the properties of good wheat-flour? Of wheaten 
bread? How is the percentage of gluten in flour determined? The presence of 
added mineral substances? What does a low percentage of gluten indicate? 
In what kind of flour are parasites, etc., found? What is a test for alum in 
bread ? Should bread contain any alum ? What flours or starches may be used 
to sophisticate wheat-flour? 



CHAPTER IV, 

SOIL. 

Hippocrates treated at length, in one of his works, of the sani- 
tary influences of the soil. Others of the older writers, especially 
Herodotus and Galen, called attention to the same subject, and Vitru- 
vius, the celebrated Eoman architect, who flourished at the beginning 
of the Christian era, taught that a point of first importance in build- 
ing a dwelling was to select a site upon a healthy soil. 

From this time until the beginning of the eighteenth century, 
very little of value is found in medical literature bearing upon this 
subject. In 1717, however, Lancisi published his great work on the 
causes of malarial fevers, in which he laid the foundation for the 
miasmatic theory of malaria, and pointed out the relations existing be- 
tween marshes and low-lying lands and those diseases by common 
consent called malarial. Other authors of the eighteenth and the 
early part of the nineteenth centuries refer to the connection be- 
tween the soil and disease, but exact investigations have only been 
made within the last thirty years. 

When it is considered that the air that human beings breathe, 
and much of the water they drink, are influenced in their composi- 
tion by the matters in the soil, the great importance of possessing a 
thorough knowledge of the physical and chemical conditions of the 
soil becomes evident to every one. 

PHYSICAL AND CHEMICAL CHARACTERS OF THE SOIL. 

In the hygienic, as in the geological sense, rock, sand, clay, and 
gravel are included in the consideration of soils. 

The soil, as it is presented to us at the surface of the earth, is 
the result of long ages of disintegration of the primitive rocks by the 
action of the elements, of the decomposition of organic remains, and, 
possibly, of accretions of cosmical dust. The principal factor, how- 
ever, is the action of water upon rock, in leveling the projections of 
the earth's surface produced by volcanic action. 

Soils vary considerably in physical and chemical constitution. 
A soil may, for example, consist exclusively of sand, of clay, or of 

(160) 



THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 161 

disintegrated calcareous matter. Other soils may consist of a mixture 
of two or more of these, together with vegetable matter undergoing 
slow oxidation. In forests, a layer of this slowly-decomposing vege- 
table matter of varying thickness is found, covering the earthy sub- 
stratum. This organic layer is called humus, and when turned under 
by plough or spade, and mixed with the sand or clay base, it con- 
stitutes the ordinary agricultural soil. 



THE ATMOSPHERE OF THE SOIL, OR GROUND=AIR. 

The interstices of the soil are occupied by air or water, or by 
both together. The soil's atmosphere is continuous with, and resem- 
bles in physical and chemical properties, that which envelops the 
earth. Its proportion to the mass of the soil depends upon the de- 
gree of porosity of the soil, and upon the amount of moisture pres- 
ent. In a very porous soil, such as, for example, a coarse sand, 
gravelly loam, or coarse-grained sandstone, the amount of air is much 
greater than in a clayey soil, granite, or marble. So, likewise, when 
the soil contains a large proportion of water, the air is to this extent 
excluded. The porosity of the various soils, as evidenced by the 
amount of air contained in them, is much greater than would, at first 
thought, be supposed. Thus, it has been found that porous sandstone 
may contain as much as one-third of its bulk of air, while the pro- 
portion of air contained in sand, gravel, or loose soil may amount 
to from 30 to 50 per cent. 

The ground-air is simply the atmospheric air which has pene- 
trated into the interstices of the soil and taken part in the various 
chemical decompositions going on there. In consequence of these 
chemical changes the relative proportions of the oxygen and car- 
bonic acid in the air are changed — oxygen disappearing and giving 
place to carbon dioxide. It is well known that during the decay of 
vegetable matter in the air carbon dioxide is formed ; one constituent 
of this compound, the carbon, being derived from the vegetable 
matter, while the oxygen is taken from the air. Hence, if this ac- 
tion takes place where there is not a free circulation of air, as in the 
soil, the air there present soon loses its normal proportion of oxygen, 
which enters into combination with the carbon of the vegetable matter 
to form carbon dioxide. 

Over thirty years ago, MM. Boussingault and Levy, two distin- 
guished French chemists, examined the air contained in ordinary 

agricultural soil, and found that the oxygen was diminished to about 

li 



162 TK\T-P»OOK OF HYGIENE. 

one-half of the proportion normally present in atmospheric air, while 
the carbon dioxide was enormously increased. The exact results 
obtained by Boussingault and Levy were as follows : — 

In 100 volumes of ground-air there were 10.35 volumes of oxy- 
gen, 79.91 volumes of nitrogen, 9.74: volumes of carbon dioxide. In 
atmospheric air, on the other hand, there are in 100 volumes 20.9 vol- 
umes of oxygen, 79.1 volumes of nitrogen, 0.04 volume, or about 
1 / 25 of 1 per cent, of carbon dioxide. 

In spite of the striking results obtained by these two chemists, 
very little attention was paid to them by sanitarians, as very few 
seemed to have any clear notion of the relations existing between the 
motions of the air above ground and that under ground. 

In 1871, however, Professor von Pettenkofer, of Munich, pub- 
lished the results of his own examinations into the constitution and 
physical conditions of the ground-air, and the relations of the latter 
to the propagation of epidemic diseases. These researches, which 
created a widespread interest in the subject, were extended by other 
observers in all parts of the world. These observers, prominent among 
whom were Professors Fleck, Fodor, and Soyka, in Germany; Drs. 
Lewis and Cunningham, in India; Professor William Eipley Mchols, 
in Boston; and Surgeons J. H. Kidder and S. H. Griffith, of the U. 
S. Navy, in Washington, demonstrated that the increase of carbon 
dioxide in the ground-air is due to increased vegetable decomposition 
and to lessened permeability of the soil. A permeable, that is to say, 
a sandy or gravelly soil is likely to contain less carbon dioxide in its 
atmosphere than a dense, less permeable clay, although the amount 
of decomposition going on and the production of carbon dioxide 
in the former may considerably exceed the latter. In the loose, sandy 
soil the circulation of the air is less obstructed, and the carbon di- 
oxide may easily escape and be diffused in the superincumbent air, 
while the close-pored clay imprisons the carbon dioxide and pre- 
vents or retards its escape into the air above. 

The disappearance of oxygen from the ground-atmosphere is coin- 
cident with the production of an equivalent amount of carbon dioxide. 
It appears from this that in the soil an oxidation of carbonaceous 
substances takes place, the product of which is found in the excess 
of carbon dioxide in the ground-air. 

Professor Nichols has found the proportion of carbon dioxide 
in the air taken from a depth of 3 metres below the surface in the 
"made-land" of Boston to amount to 21.21 per thousand, the obser- 
vation having been made in August. In December, at a depth of 2 



THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 163 

metres, the proportion was 3.23 per thousand. Fodor, in Buda- 
Pesth, found the proportion of carbon dioxide to be 107.5 per thou- 
sand (over 10 per cent.), the air having been taken from a depth of 
3 metres. 

The ground-air also teems with micro-organisms of various kinds, 
these being occasionally pathogenic. While in the great majority of 
instances the micro-organisms found are ordinary mold or fermen- 
tation fungi and bacteria of decay and putrefaction, disease-produc- 
ing bacilli have also been observed in a number of instances. Among 
the latter are the bacillus of tetanus (Mcolaier), of anthrax (Frank), 
of malignant edema (Koch and Gaffky), and of typhoid fever (Tryde) . 

It may not be inappropriate to refer here to the claim of Pro- 
fessor Domingos Freire, of Brazil, to the discovery of the germ of 
yellow fever in the soil of a burial ground near Eio Janeiro. The 
exhaustive investigations of Surgeon-General G. M. Sternberg, of the 
IT. S. Army, under the direction of the government, have disposed 
effectually of the claims and pretensions of the Brazilian scientist, 
and established the fact that Freire's organism has no pathological 
significance whatever — at all events, that it has no relation to yellow 
fever. 

Cholera bacilli have not been found in the soil, but C. Frankel 
has shown experimentally that they can grow and multiply in the soil 
at various depths. At a depth of l 1 / 2 metres their development was 
constant and progressive throughout the year. With regard to ty- 
phoid bacilli, Houston found that under ordinary condition they die 
out in the course of a few days to a few weeks. 

When the soil is dry, these organisms may be carried hither and 
thither in the movements of the ground-air, and thus be transported 
to a distance. 

Movements of the ground-atmosphere are principally due to dif- 
ferences of pressure and temperature in the air above ground. Owing 
to such differences the air from the soil frequently permeates houses, 
entering from cellars or basements. In winter, when the air of houses 
is very much more heated (and consequently less dense) than the air 
out-of-doors, the difference of pressure thus caused draws the ground- 
air up through the house, while the cold, external atmosphere pene- 
trates the soil and occupies the place of the displaced ground-air. 1 
A similar effect occurs in consequence of heavy rains. The water fills 

*It is, of course, not strictly correct to say that the air is drawn up 
through the house by the diminution of pressure; it being rather forced out 
of the soil bv the colder and denser outside air; but the phrase is sufficiently 
exact and will be readily understood. 



1C>4 TEXTBOOK OF HYGIENE. 

up the interstices of the soil near the surface, and forces the ground- 
air out at points where the pores remain open. These places are the 
dry ground under buildings, whore the air escapes and passes through 
floors and ceilings into the house above. Heavy rains may thus be 
the cause of pollution of the air in houses. The greater the porosity 
of the soil, the more likely is this to happen. This pollution of the 
house-air may be prevented by having impervious floors and walls 
to cellars and basements, or by interposing a layer of charcoal between 
the ground and the floor of the house. The latter does not prevent 
the passage of the ground-air, but the charcoal layer absorbs or arrests 
the noxious matters — niters the ground-air, as it were. 

In the spring and early summer the ground being colder than 
the air above it, and the ground-air consequently heavier and denser, 
the. latter is not easily displaced. It is, perhaps, due to this fact that 
those infectious diseases which are probably dependent upon the 
movements of the ground-air are less prevalent in the spring and 
early summer than in the latter part of the summer, autumn, and 
early winter. In the autumn the ground-air being warmer than the 
air above ground is easily displaced by the latter and forced out into 
the streets and houses to be inspired by men and animals. The 
colder outside air penetrates the interstices of the soil and forces 
out the impure ground-air. 

The researches of Fodor have demonstrated that the propor- 
tion of carbon dioxide in the ground-air may be taken as an approxi- 
mate measure of the impurity of the soil whence the air is taken. 
The influence of the permeability of the soil, as before pointed out, 
must, however, not be overlooked in estimating the signification of 
the carbon dioxide. Fodor has shown that the proportion of carbon 
dioxide in the ground-air, and consequently the amount of organic 
decomposition, is greatest in July and least in March. That the car- 
bon dioxide is derived from the decomposition of vegetable matter 
has been proven by Pettenkofer. This observer examined specimens 
of air brought from the Lybian desert, and found that the propor- 
tion of carbon dioxide in the ground-air was exactly the same as in 
the air collected above ground. There being no vegetable growth 
in the desert there can, of course, be no vegetable decomposition going 
on in the soil. 

The excess of carbon dioxide in the ground-air is an indication 
of the deficiency of oxygen, as has been shown. The air at a depth of 
4 metres below the surface was found to contain only from 7 to 10 
per cent, of oxygen — one-half to one-third of the normal proportion. 



THE WATER^OE THE SOIL, OR GROUND- WATER. 165 

Many basements occupied by people as living-rooms extend from 1 to 
3 metres underground, and hence are liable to be supplied with an 
atmosphere approaching in impurity that just mentioned. It requires 
no very vivid imagination to appreciate the dangers to health that 
lurk in such habitations. 



THE WATER OF THE SOIL, OR GROUND=WATER. 

At a variable' depth below the surface of the ground, a stratum 
of earth or rock is found through which water passes with difficulty, 
if at all. Above this there is a stratum of water which moves from 
a higher to a lower level, and which varies in depth at different times 
according to the amount of precipitation (rain- or snow- fall), and 
according to the level of the nearest body of water toward which it 
flows. This stratum of water is termed ground-water, and has within 
the last few years assumed considerable importance from its appar- 
ently close relation to the spread of certain of the infectious diseases. 
The direction of horizontal flow of ground-water is always toward 
the drainage-area of the district. Thus, it is usually toward lake?, 
rivers, or the sea. _Eains, or a rise in the river, cause a rise in the 
ground-water, while long-continued dry weather, or a low stage of the 
river .which drains off the ground-water, causes a fall in the latter. 
On the sea-coast the ground-water oscillations probably correspond 
with the tides. The writer is not aware of any observations made 
to determine this point, with the exception of a single instance men- 
tioned by Dr. De Chaumont. In Munich, where the ground-water 
flows toward the river Isar, which divides the city, it has been found 
that the annual range or oscillation (the difference between the high- 
est and lowest level during the year) is about 3 metres, while the 
horizontal movement amounts to 5 metres per day. In Buda-Pesth 
the annual range was found by Fodor to be less than 1 metre, while in 
some portions of India it amounts to more than 12 metres. As it is 
from the ground-water that the greater portion of the supply of 
drinking-water in the country and in villages and small towns is 
drawn, it becomes at once manifest how important it is to prevent, as 
far as possible, pollution of this source. Cess-pools and manure-heaps 
and pits, of necessity, contaminate the soil and also the ground- 
water for a distance below and around them, and such water is 
clearly unfit for drinking and other domestic purposes. Hence, the 
reason why wells should not be placed too near privies and manure- 
heaps or pits becomes apparent. 



166 TEXT-BOOK OF HYGIENE. 

Between the level of the ground-water, or that portion of the 
soil where its pores are entirely occupied by water — where, in other 
words, the ground is saturated — and the surface, is a stratum of earth 
more or less moist; that is to say, the interstices of the soil are partly 
filled with water and partly with air. It is in this stratum that the 
processes of organic decay or putrefaction are most rapidly going on, 
in consequence of which the pollution of the ground-air occurs. The 
oxidation of non-nitrogenous matter in the soil results in the forma- 
tion of carbon dioxide. On the other hand, nitrogenized compounds 
are oxidized into nitric acid and nitrates. When, however, putrefac- 
tion occurs, nitrous acid, or nitrites and ammonia, are formed, the 
oxidation not proceeding far enough to result in nitric acid. 

Eecent observations seem to show that these processes of decom- 
position are initiated and kept up by bacteria, just as fermentation 
in liquids containing sugar can only take place in the presence of the 
yeast-plant. It has been found that when non-putrefactive decompo- 
sition goes on, there are always present multitudes of one variety of 
these minute organisms; while if putrefactive decomposition is going 
on, a number of other varieties of these organisms are present. Just 
as, when a fermenting liquid becomes putrid, the yeast-plant disap- 
pears and its place is taken by the ordinary bacteria of putrefac- 
tion, so in the soil, if the access of oxygen, which is necessary to the 
life of the bacteria of decay, is prevented, these organisms die and 
are succeeded by the organisms of putrefaction. It has been found 
that in a soil saturated with water the bacteria of decay cannot live, 
while those of putrefaction may flourish, because these latter organ- 
isms can sustain life and develop in the absence of oxygen. Professor 
Fodor's researches indicate that the most prominent organism of non- 
putrefactive decomposition or decay is that which is termed by Cohn 
bacterium lineola; and that the bacterium termo is the principal 
organism of putrefaction. 



DISEASES SPREAD BY SOIL IMPURITIES. 

Given now an area of soil, say the ground upon which a house 
or city is built, with a moist stratum in which the processes of decay 
are active, and imagine a rise in the ground-water. The* ground-air, 
charged with carbon dioxide and other products of decomposition, is 
forced out of the pores of the soil by the rising ground-water, and 
escapes into the external air, or through cellars and basements into 
houses, and may there produce disease. But the saturation of the 



DISEASES SPREAD BY SOIL IMPURITIES. 107 

soil with water prevents the further development of the bacteria of 
decay, and this is checked, or putrefaction may take place. If now 
the ground-water sinks to its former level or below, the processes of 
decay again become very active in the moist stratum, and large 
quantities of carbon dioxide and other inorganic compounds are 
produced. If the germs of infectious or contagious diseases have been 
introduced into the soil, they also multiply and, by gaining access to 
the well or stream from which the drinking-water is obtained, they 
may cause infection. Professor De Cbaumont has laid down the rule 
that a soil with a persistently low stage of ground-water, say 5 metres 
below the surface of the ground, is healthy; a persistently high stage 
of ground-water, less than l 1 / 2 metres below the surface, is unhealthy ; 
while a fluctuating level of the ground-water, especially if the changes 
are sudden and violent, is very unhealthy. This would lead us to 
expect that places where this fluctuation is very great would show 
a large mortality from such diseases as are attributed to impurities in 
the soil. And this we find especially true in India. In certain local- 
ities in India, cholera, for example, is endemic; that is to say, the 
disease is never entirely absent in such localities. Calcutta is one of 
these places. The rainy season begins about the first of May and con- 
tinues until the end of October. During the next six months there 
is very little rain. It is fair to assume that the ground-water rises 
during the rainy season and checks decay and the multiplication of 
the germs of the disease in the soil, and that these processes become 
more active as the dry season advances and the ground-water level 
falls. If we note the death-rate from cholera in Calcutta it will be 
found that it bears a distinct relation to the movement of the ground- 
water. The deaths from cholera begin to increase from October and 
reach their height in April. Dr. Macpherson, who has written a very 
elaborate history of Asiatic cholera, shows this relation very clearly. 
For twenty-six years the average rain-fall was 157 centimetres. From 
May to October 142 centimetres fell, while the remaining 15 centi- 
metres fell from November to April. The average number of deaths 
from cholera annually was 4013. Of these, 1238 died in the rainy 
season, while 2775, nearly three-fourths, died during the period of 
dry weather. 

In the cholera epidemics of 1866 and 1873 in Buda-Pesth, the 
same relations existed between the ground-water and the cholera. As 
the level of the ground-water rose the cholera diminished, while the 
disease increased upon the sinking of the ground-water. Exactly the 
same behavior was exhibited by the disease in Munich in 1873. 



168 TEXT-BOOK OF HYGIENE. 

There seems good reason to believe that typhoid fever bears some 
relation to the movements of the ground-water in the same way as 
above explained for cholera. Pettenkofer, Buhl, and Virchow have 
shown that the death-rate from typhoid fever has a distinct and 
definite relation to the ground-water oscillations. This has been in- 
contestable proven for two cities, Munich and Berlin. When the 
level of the ground-water is above the average, typhoid fever de- 
creases; when it is below the average, the number of cases becomes 
greater. Dr. H. B. Baker has demonstrated that the fluctuation 
of the ground-water level in the State of Michigan is similarly fol- 
lowed by a change in the morbidity and mortality from typhoid fever. 2 

Over thirty years ago Dr. Henry I. Bowditch, of Boston, called 
attention to the frequent connection between cases of pulmonary con- 
sumption and dampness of the soil upon which the patients lived. 
After a very extended and laborious investigation Dr. Bowditch for- 
mulated these two propositions : — 

''First. — A residence in or near a damp soil, whether that damp- 
ness be inherent in the soil itself or caused by percolation from ad- 
jacent ponds, rivers, meadows, or springy soils, is one of the prin- 
cipal causes of consumption in Massachusetts, probably in Xew Eng- 
land, and possibly other portions of the globe. 

"Second. — Consumption can be checked in its career, and possi- 
bly — nay, probably — prevented in some instances by attention to this 
law." 3 

Dr. Buchanan, of England, about the same time showed that 
the thorough drainage of certain English cities had markedly dimin- 
ished the deaths from consumption in the drained cities. So far as 
the writer is aware, not a single fact has been established which 
militates against the law laid down by Dr. Bowditch, and so strongly 
supported by the statistical researches of Dr. Buchanan, yet hardly 
any notice has been taken of these results by physicians. Few know 
anything of them, and still fewer seem to have made practical use 
of such knowledge in advising patients. As corroborative of the views 
of Dr. Bowditch, the rarity of consumption in high and dry moun- 
tainous districts or plateaus may be cited. 

A study of the topographical distribution of consumption in the 
State of Pennsylvania, by Dr. William Pepper, apparently confirms 
Dr. Bowditch's conclusions in nearly every particular. It is now 

2 The Relation of the Depth of Water in Wells to the Causation of 
Typhoid Fever, Public Health, vol. x, p. 184-213. 

s Consumption in New England and Elsewhere, 2d ed., p. 87. Boston. 
1866. 



DISEASES OF ANIMALS DUE TO CONDITIONS OF SOIL. 169 

known that the direct cause of consumption is the bacillus tuberculosis, 
discovered by Dr. Robert Koch. The relation between soil-moisture 
and the increase of consumption will probably be found in the more 
favorable conditions of development of the tubercle bacillus fur- 
nished by a moist medium. 



DISEASES OF ANIMALS PROBABLY DUE TO SIMILAR 
CONDITIONS OF THE SOIL. 

The modern study of the sanitary relations of the soil is still in 
its infancy. Whatever definite knowledge has been gained relates 
merely to physical or chemical conditions of the soil and its atmos- 
phere and moisture, or possibly the relations of these to the spread 
of certain diseases in human beings. But there is, perhaps, a wider 
application that may be made of such knowledge than has been here- 
tofore suggested. The domestic animals which form such a large por- 
tion of the wealth of this country — horses, cattle, sheep, and hogs — 
are liable to infectious and contagious diseases, as well as are human 
beings, and many millions of dollars are lost annually by the ravages 
of such diseases. Now, from what is known of such diseases as 
splenic fever among cattle, and of the so-cal'ed swine-plague, it does 
not appear improbable to the writer that the source of infection is a 
soil polluted by the poisonous germ of these diseases. The laborious 
investigations of M. Pasteur in France have shown that the cause of 
splenic fever, when once introduced into a locality, will remain active 
for months, and even years, and it seems probable that a study of the 
soil in its relation to the diseases of domestic animals is a subject to 
which attention may profitably be given. 

It is well known that milch-cows frequently suffer from a disease 
identical in its nature with consumption in human beings. It is be- 
lieved by many that the milk of such animals is not only unfit for 
food by reason of its poor quality, but that it may convey the dis- 
ease to human beings when used as food. The observations of Bow- 
ditch and Buchanan, quoted above, show that consumption in man 
may be, and doubtless is, frequently favored by soil-wetness. It seems 
probable that the same cause should produce similar effects in the 
lower animals, and it is the writer's firm conviction that an exam- 
ination into the circumstances under which cows become attacked by 
consumption would prove this probability a fact. 



170 TEXT-BOOK OV HYGIENE. 

DRAINAGE, 

In many soils drainage is necessary in order to secure a constant 
level of the ground-water at a sufficient depth below the surface. 
Drainage and sewerage must not be confounded with each other. 
Drainage contemplates only the removal of the ground-water, or the 
reduction of its level, while sewerage aims to remove the refuse from 
dwellings and manufactories, including excrementitious matters, 
waste-water, and other products, and in some cases the storm-water. 

Sewers should never be used as drains, although for economy's 
sake sewer- and drainage- pipes may be laid in the same trench. 
Sewer-pipe must be perfectly air-tight and water-tight to prevent 
escape of its liquid or gaseous contents into the surrounding soil and 
rendering it impure. Drainage-pipe, on the other hand, should be 
porous and admit water freely from without. Escape of the contents 
of the drain-pipe into the surrounding soil will not produce any pol- 
lution of the latter. 

The best material for drains is porous earthenware pipe, or the 
ordinary agricultural drain-tile. Coarse gravel or broken stones may 
a 1 so be used, and prove efficient if the drains are properly constructed. 
Eeferring again to the aphorism of Professor De Chaumont, that a 
persistently low ground-water, say 5 metres down, or more, is healthy ; 
that a persistently high ground-water, less than l 1 /, metres from the 
surface, is unhealthy, and that a fluctuating level, especially if the 
changes are sudden and violent, is very unhealthy, the necessity ap- 
pears obvious, that in the construction of drainage-works the drains 
should be placed at a sufficient depth to secure a level of the ground- 
water consistent with health. This depth should never be less than 
3 metres, and, if possible, not less than 5 metres. Care must be taken 
that the outflow of the drain is unobstructed, in order that the soil 
may be kept properly dry at all times. 

In the absence of a proper mechanical system of drainage, the 
planting of certain trees may efficiently drain the soil. It has been 
found that the eucalyptus tree has produced drying of the soil when 
planted in sufficient numbers in marshy land. The roots absorb 
a prodigious quantity of water, which is then given off by evapora- 
tion from the leaves. Sunflower-plants have a similar effect upon 
wet soils. It is for this reason that the planting of eucalyptus trees 
is recommended in malarial regions. 



QUESTIONS TO CHAPTER IV. 

THE SOIL. 

Why is it necessary to possess a knowledge of the physical and chemical 
conditions of the soil? What substances are included in the consideration of 
soils? Of what is the surface soil composed? How do soils vary in composi- 
tion, physically and chemically? 

What occupies the interstices of the soil? Upon what does the propor- 
tion of air in the soil depend? Is this proportion comparatively great or 
small? What relation has the soil-air to the atmosphere air, and what causes 
the difference in composition? In what way does the soil-air differ from the 
atmospheric air? Has the soil-air any definite composition? What are the 
factors governing the variation in composition? What kind of a soil will be 
likely to contain most carbon dioxide and least oxygen? What does this indi- 
cate? What micro-organisms are always to be found in the soil-air? What 
pathogenic organisms may also make the soil and soil-air their habitat? How 
may these be carried from place to place? To what are movements of the 
ground-air due? How may this soil-air gain access to our houses, and what 
measures should be taken to prevent its entrance? When is the danger 
greatest? Why are certain infectious diseases less prevalent in spring and 
early summer than in autumn? W T hy is there greater danger of infection from 
these diseases at night than in the day-time? Is the carbon dioxide of the 
soil-air a measure of the impurity of the soil? Wliat causes the excess of 
carbon dioxide? When is the proportion of carbon dioxide greatest? Why 
are living-apartments below the surface of the ground very apt to be un- 
healthy? 

"What is meant by the term "ground- wa ter" ? Where is it to be found? 
Has it a definite current? In what direction is the flow? Upon what does 
the level of the ground- water depend? What class of the population derive 
their drinking-water largely from the ground-water? WTiat are some of the 
sources of contamination of the ground- water ? What are some of the deduc- 
tions to be made accordingly? 

In what part of the soil do the processes of organic decay and putrefac- 
tion occur most readily? What are the causes of these processes? What are 
some of their products? What is the distinction between non-putrefactive 
decomposition or decay and putrefaction? 

How may disease be spread by the rise and fall of the ground- water ? 
What two infective diseases are especially apt to be transmitted in this way? 
Give instances that tend to prove this. Upon w 7 hat other disease has a damp 
soil a directly causative influence? What diseases of animals are likely to be 
influenced in a similar manner? How deep below the surface should the soil- 
water persistently be that the soil may be healthy? What effect upon health 
has a suddenly and markedly fluctuating soil-water? Is a soil with its water 
persistently near the surface apt to be healthy? 

What do we mean by drainage, and what are its object and function? 
What is the difference between it and sewerage? How should drains be laid? 
What is the best material for drains? What precautions must be observed in 
the laying of drains? How may the surplus water be taken from the soil 
otherwise than by drains? 

(171) 



CHAPTER V. 

REMOVAL OF SEWAGE. 

In all larger communities certain arrangements are necessary to 
secure a prompt and efficient removal of excreta and the refuse and 
used water of households and manufacturing establishments, the 
sweepings of streets, and rain-water. 

The total quantity of excrementitious products — feces and urine 
— for each individual, including men, women, and children, has been 
estimated by Professor von Pettenkofer as 90 grammes of fecal and 
1170 grammes of urinary discharge daily. This would give for a 
population of 1000 persons 34,000 kilogrammes of feces and 428,000 
litres of urine per year. If to this is added a minimum allowance 
of 159 litres of water per day to each individual, a complete sewerage 
system for a population of 1000 persons would require provision for 
the discharge of 160,000 litres of sewage passing through the sewers 
every day. In this estimate storm-water and such accessory feeders 
of the sewers are omitted. 

The organic matters contained in sewage, even if free from the 
specific germs of disease, give rise to noxious emanations, which, when 
inhaled, probably produce a gradual depravement of nutrition that 
renders the system an easier prey to disease. For this and other 
reasons it is important that such measures be adopted as will secure 
the removal of sewage matters from the immediate vicinity of houses 
as quickly as possible after they have been discharged. 

The impregnation of the soil with sewage produces a contamina- 
tion of ground-air and ground-water, which may become a source of 
grave danger to health. By polluting the ground-water it eventually 
vitiates the well-water, which is nearly always derived from that 
source. 

The system of removal of excrementitious matters which any 
community will adopt depends to a considerable extent upon financial 
considerations. Although the sanitarian must insist upon the pre-emi- 
nent importance of the cause of public health, his suggestions will re- 
ceive little attention from municipal or State legislatures unless they 
can be carried out without involving the community too deeply in debt. 
For this reason it is a matter of great practical importance that the 
(172) 



REMOVAL OF SEWAGE. 173 

student of sanitary science should make himself familiar with the 
relative cost as well as with the hygienic significance of the various 
methods of sewage removal in use. 

The different systems in use for the removal of sewage matters 
may be considered in detail under the following five heads: — 

1. The common privy, or privy-vault system. 

2. The Rochdale or pail system, and its modifications. 

3. The earth- or ash- closet system. 

4. The pneumatic system of Liernur. 

5. The water-carriage systems. 

1. The Privy and Privy-well Systems. — While from a sanitary 
point of view privies of all kinds, whether wells or cess-pits, are to 
be unreservedly condemned, it is not likely that they will cease to 
be built for many years to come. It becomes necessary, therefore, to 
point out by what means the objections against them may be dimin- 
ished, and their evil consequences in some measure averted. 

In the first place, a privy-vault should be perfectly water-tight, 
in order to prevent pollution of the surrounding soil by transudation 
of the contained excremental matters. The walls should be of hard- 
burned brick laid in cement. The cavity should be small in order that 
the contents may be frequently removed, and not allowed to remain 
and putrefy for months or years. A water-tight hogshead sunk in the 
ground makes an economical privy-tank or receiver. A privy must 
not be dug in a cellar, or in too close proximity to the house-walls. 
Unless these last precautions are taken the offensive gases from the 
mass of decomposing fecal matter in the privy will constantly ascend 
into and permeate the air of the house. 

All privies should be ventilated by a pipe passing from just under 
the privy-seat to a height of about a metre above the roof of the 
house. A gas-flame, kept burning in the upper portion of this pipe, 
will increase its ventilating power by creating a strong and constant 
upward current. 

Deodorization of the contents of privies may be secured in a 
measure by means of sulphate of iron, phenyle, carbolic acid, chloride 
of lime, or dry earth. The first named is probably the most econom- 
ical, most easily applied, and very effective. A solution containing 
from 1 / 2 to 1 kilogramme of the salt in 4 litres of water is poured 
into the privy as often as necessary to prevent offensive odors. This 
solution may be conveniently prepared by suspending a basket or 
bag containing about 25 kilogrammes of the sulphate in a barrel of 






174 TEXT-BOOK OF HYGIENE. 

water. In this way a saturated solution will be maintained until the 
salt has been entirely dissolved. Phenyle is likewise a good deodor- 
izer as well as an excellent disinfectant. 

The most rigid deodorization by chemicals will, however, be less 
effective than thorough ventilation, for it must be remembered that 
the mere destruction of an offensive odor is not equivalent to remov- 
ing all the deleterious properties that may be present. It is not at 
all certain that those elements of sewage which are the most offensive 
to the sense of smell are most detrimental to health. 

Privies should be emptied of their contents at stated intervals. 
A strict supervision should be exercised over them by the municipal 
authorities in cities and towns to prevent overflowing of their con- 
tents. 

In many places the method of removing the contents of privies 
is the primitive one with shovel, or dipper and bucket. In most 
cities and large towns, however, the privy-vaults or tanks are now 
emptied by means of one of the so-called odorless excavating machines, 
of which there are a number of patents. The process is rarely 
entirely odorless, however, as the carelessness of the workmen fre- 
quently permits offensive gases to escape and pollute the air for a 
considerable distance. All the different forms of the apparatus act 
upon the pneumatic principle. One end of a large tube is carried 
into the cess-pool or vault to be emptied and the other attached to 
a pump, by means of which the material is pumped into a strong bar- 
rel-tank carried on wheels. At the top of the tank is a vent, over 
w r hich is placed a small charcoal furnace to consume the foul gases 
escaping from the vent. 

In some cities and many of the smaller towns and villages in 
this country the primitive midden or pit system is still in use. A 
shallow pit is dug in the ground, over which is erected the privy. 
When the pit is full another is dug close by the side of it, and the 
earth from the new pit thrown upon the excrement in the old one. 
The privy is then moved over the new pit, and this is used until it 
too becomes full. The proceeding is repeated as often as the pit be- 
comes filled up with the excreta, until in the course of a few years all 
the available space in a yard has been honey-combed with the pits. 
Then the custom adopted in overcrowded cemeteries is followed, 
namely, the first pit is dug out again and the cycle is repeated. 

In other cities the privy-well system is largely in use. This is — 
next to the midden or shallow pit just described — the most pernicious 
system for the disposal of excreta that can be imagined. The wells 



REMOVAL OF SEWAGE. 175 

are dug to such a depth as to reach the subterranean flow of water, 
in which the soluble excremental matters are constantly carried off. 
Hence these receptacles rarely fill up or need cleaning. For this 
reason they are popular with property owners ; for, next to the primi- 
tive midden, they are the most economical of all the various methods 
adopted. The utter perniciousness of the system is, however, plain, 
because the soil for a considerable distance around each of these wells 
becomes a mass of putrid filth, contaminating the ground-water which 
feeds the drinking-water supplies in the vicinity; polluting also the 
ground-air, which eventually reaches the surface, or the interior of 
houses, when the pressure of the outside atmosphere diminishes or 
the ground-water level rises. It must, therefore, be evident that the 
best ventilating arrangements, or the most thorough and consistent 
disinfection, can have very little, if any, effect in removing the very 
grave objections to this baneful system. 

The privy-well system for the removal of excreta cannot be recom- 
mended for adoption by any sanitarian. 

2. The Rochdale, or Pail-closet System. — The Eochdale system 
of removal of excreta has won the support of many distinguished 
sanitarians on account of its simplicity, its economy, and its com- 
pliance with most sanitary requirements. The excreta, both solid 
and liquid, are received into a water-tight pail, either of wood or 
metal, and removed once or oftener a week, a clean and disinfected 
pail being substituted for the one removed. In Eochdale, Manchester, 
and Glasgow in Great Britain, in Heidelberg in Germany, and 
in other cities abroad, where this system has been introduced, 
it has worked satisfactorily. In this country a modification 
of the pail system, known as the Eagle Sanitary Closet, has been in- 
troduced by a firm in Charleston, S. C. The receptacle consists of 
an enameled-iron reservoir, with a neck just large enough to fit under 
the seat of the privy, and a quantity of disinfectant solution is put 
into the receptacle to prevent putrefaction of the excreta. The re- 
ceptacles are replaced by clean ones every week. 

Mr. James T. Gardner, Director of the New York State Sanitary 
Survey, says, in a special report on methods of sewerage applicable 
in small towns and villages, concerning the pail system 1 : — 

"Eochdale is a city of some 70.000, and Manchester of between 
400,000 and 500,000 inhabitants. The higher class of houses are al- 
lowed to have water-closets, but four-fifths of the people are obliged 

1 Second Annual Report of New York State Board of Health, pp. 322, 
and 323. 



170 IK XT-BOOK OF HYGIENE. 

to have 'pail-closets' in their yards built according to plans of the 
Health Department. Their essential features are: A flag-stone floor, 
raised a few inches above the level of the yard; a hinged seat, with a 
metal rim underneath for directing urine into the pail, which stands 
on the flag directly beneath the seat; a hinged front and back to 
the seat, so that the pail or tub may be easily taken out and the place 
cleaned; and a 6-inch ventilating pipe from under the seat to above 
the roof. In Eochdale they use a wooden pail or tub made of half 
of a disused paraffme cask, holding about 40 kilogrammes; in Man- 
chester the f paiP is of galvanized iron and holds 40 litres. Under the 
direction of the authorities, they are removed once a week in covered 
vans, which bring clean tubs to be put in the place of the full ones 
taken away. Each tub is covered with a close-fitting double lid before 
removal. The tubs are taken to a depot, where their contents are 
deodorized and prepared as manure by mixing with ashes and a small 
proportion of gypsum to fix the ammonia. Subsequently, street- 
sweepings and the refuse of slaughter-houses are added. At # Man- 
chester there is by the side of each closet a very simple ash-sifter, 
from which the ashes fall into the tub and help to deodorize its con- 
tents. 

"The manure at Eochdale sells for about four-fifths of the cost 
of the collection and preparation. 

"In 1873 the net cost to the town of removing and disposing of 
the house dry refuse and excrement w r as only about $95 per annum 
per 1000 of population — less than 10 cents a person per annum. 

"The system has been in operation more than twelve years. 

"The tubs are removed in the daytime without offensive odor. 

"Where ashes are frequently thrown into the tubs at Manchester, 
very little odor is to be perceived in the closets. 

"For the villages of the State, which can have no general water- 
supply, I would unhesitatingly advise the use of the 'paiP or tub 
system as practiced in Manchester, England, as being, from a sanitary 
point of view, an immense improvement over the death-breeding privy- 
vaults in common use. The cheapness of the plan and the smallness 
of the original outlay of brains and money, in comparison with that 
needed to build a good 'sewer system, will make it possible to introduce 
a tub-privy system into most villages half a century before sewers 
would meet with any consideration. 

"At a small cost the existing privy-vaults can be cleaned and 
filled, and the privies altered into healthful tub-closets. The town 
authorities must then arrange for the removal of the tubs once a 



REMOVAL OF SEWAGE. 



177 



week, and for their thorough cleansing and disinfecting. Any iso- 
lated house, or group of houses, can use the tub system, taking care of 
it themselves. If the plan is adopted in villages it will doubtless 
spread into the country, and become the most powerful means of 
abolishing the fatal privy-vaults which are poisoning the farm-wells." 
3. Earth- and Ash- Closets. — The earth- and ash- closets are 
devices in use to a large extent in England, and to a less degree in 
this country, for the purpose of rendering human excreta inodorous 
by covering them immediately after they are voided with dry earth 





Fig. 11. 



Fig. 12. 



Fig. 11. — Pull-up Handle Commode, Showing the Door Open for 
Removing Pail. The flap of the seat and earth reservoir are also 
partially raised to show the construction. 

Fig. 12. — Showing the Apparatus Mounted on Bearers as when 
Fixed. Seat removed, showing mechanical arrangement. 



or ashes. The earth-closet is the invention of the Eev. Henry 
Moule, of England, and consists of an ordinary commode or closet, 
the essential feature of which is a reservoir containing dried earth 
or ashes, a quantity of which, amounting to about twice the quantity 
of feces voided, is thrown upon the evacuation either by hand or by 
means of an automatic apparatus called a "chucker." Just as in 
the ordinary water-closet, by raising a handle a supply of water is 
thrown into a hopper to wash down the feces into the soil-pipe, so, in 
the usual form of the earth-closet, raising the handle projects a quan- 

12 



178 



TEXT-BOOK OF HYGIENE. 



tity of earth upon the evacuated feces and urine. By this means the 
excreta are rendered entirely inodorous and dry. The contents of 
the closets may be collected into a heap in a dry place. In the 




course of a few months the organic constituents have become oxi- 
dized, and the earth may be used over again for a number of times. 
A well-known sanitarian states that he has used sifted anthracite 
coal-ashes ten or twelve times over in the course of three years. 
During this time the material under no circumstances gave any indi- 



REMOVAL OF SEWAGE. 179 

cation that it was "anything but ashes, with a slight admixture of 
garden-soil." 2 

Dr. Buchanan, of England, comparing the advantages of the 
earth-closet with those of the water-closet, says: "It is cheaper in 
original cost; it requires less repairs; it is not injured by frost; it 
is not damaged by improper substances being thrown down it; and it 
very greatly reduces the quantity of water required by each house- 
hold." 3 

In cities and towns the removal of the excreta should be carried 
out by or under the immediate direction of the municipal sani- 
tary authorities. If this is neglected, abuses are liable to creep in 
which will vitiate the performance of any system, however faultless 
when properly managed. 

Many advocates of the pail, dry earth, or privy systems urge the 
advantage of the large quantity of valuable manure which can be 
realized by converting the excremental matters into poudrette and 
other fertilizing compounds. Experience has .shown, however, that 
the cost of preparing a satisfactory fertilizer from human excrement 
is much greater than can be realized from its sale. In all places in 
Great Britain and the continent of Europe where it has been tried 
the decision is against its practicability. The agricultural consider- 
ation should, however, be a secondary one, if the systems mentioned 
are economical and meet the sanitary requirements (which the privy 
system certainly does not). The adoption of one or other of them 
may be secured where more perfect but more complicated and ex- 
pensive systems may be out of the question. 

4. The Pneumatic System of Liernur. — A system which seems 
to be useful in larger cities, especially where the topographical condi- 
tions are such as to render necessary mechanical aid in overcoming ob- 
stacles to natural drainage, is the pneumatic system devised by Captain 
Liernur, of Holland, and generally known as the Liernur system. It 
consists of a set of soil-pipes running from the water-closets to cen- 
tral district reservoirs, from which the air is exhausted at stated 
intervals. When a vacuum is created in the reservoir the contents of 
the water-closets and soil-pipes are driven forcibly into the reservoir 
by the pressure of air. The district reservoirs are connected by a 
separate system of pipes with a main depot, and the transfer of the 
fecal matter from the former to the latter is also accomplished with 



2 The Sanitary Drainage of Houses and Towns, Waring, p. 250. 2d ed. 
1881. 

3 Quoted in Waring, above cited, p. 264. 



ISO TEXT-BOOK OF HYGIENE. 

the aid of pneumatic pressure. The complete system of Liernur 
provides that at the main depot the fecal matter shall be treated with 
chemicals, evaporated, and. converted into a dry fertilizer — poudrette. 
It appears from the published reports that while the system has been 
partially adopted in three Dutch cities, in only one of them, Dor- 
trecht. has the machinery for manufacturing poudrette been estab- 
lished. With reference to this Erismann* says : "It seems never 
to have been in regular working order, for the fecal masses are mixed 
with street-sweepings and ashes into a compost-mass which causes no 
little discomfort in the neighborhood by the offensive odors. In 
Amsterdam the fecal matters, which frequently do not find a ready 
sale, are partly made into a compost with sweepings, partly used to 
fertilize meadows, or simply discharged into the water." 

As to the practical working of the system the opinions differ 
widely. While the majority of sanitarians, including Virchow, von 
Pettenkofer, and Mr. Eawlinson, objected to it as not fulfilling the 
demands of hygiene, the system has also been criticized by engineers 
as not being in accordance with the well-known principles of their 
science. 5 

Two other plans for the removal of fecal matter by pneumatic 
pressure have been invented, namely, the Shone and the Berlier sys- 
tems. Neither of these has been adopted to any considerable extent. 
Both seem to the author to fall far short even of the merits of the 
Liernur system. 

5. The Water-carriage System of Sewerage. — Two systems of 
removal of sewage by water-carriage are in use at the present time. 
They are technically known as the "combined" and the "separate" 
systems. In the former, which is the system upon which the most 
of the sewers in this country are constructed, all excreta, kitchen- 
slops, waste-water from baths and manufacturing establishments, as 
well as storm-water, are carried off in the same conduits. In the 
separate system, on the other hand, the removal of the storm-water 
is provided for, either by surface or underground drains, not con- 
nected with the sewers proper, in which only the discharge from 
water-closets and the refuse-water from houses and factories are 
conveyed. In the separate system the pipes are of such small calibre 



4 Von Pettenkofer und Ziemssen: Handbuch der Hygiene. II Th., IT 
Abth., 1 Hefte, p. 140. 

"Papers by Maj. C. H. Latrobe and Col. Geo. E. Waring, Jr., in Fifth 
Biennial Report Md. State Board of Health. See also, in favor of system, a 
paper by Dr. C. W. Chancellor, in same publication, and an elaborate descrip- 
tion by the same author in Trans. Med. and Chir. Faculty of Md., 1883. 



REMOVAL OF SEWAGE. 181 

that a constant flow of their contents is maintained, preventing 
deposition of suspended matters and diminishing decomposition and 
the formation of sewer-gas. 

In the combined system, on the other hand, the sewers must be 
made large enough to receive the maximum rain-fall of the district. 
This requires a calibre greatly in excess of the ordinary needs of the 
sewer, and furnishes favorable conditions for the formation of sewer- 
gas and the development of minute vegetable organisms. The ordi- 
nary flow in a sewer of large calibre is usually so sluggish as to 
promote the deposition of solid matters and the gradual obstruction 
of the sewer. 

It is the opinion of the most advanced sanitarians that the sepa- 
rate system fulfills the demands of a rational system of sewerage 
better than any other at present in use. 

The separate system of sewage, indorsed as it is by high engi- 
neering and sanitary authorities, and by a satisfactory, practical test 
in the city of Memphis and in the town of Keene, N. H., seems to 
the author to possess merits above any other plan for the removal of 
excreta and house-wastes. The following description is from a paper 
by Colonel George E. Waring, Jr. : "A perfect system of sanitary 
sewerage would be something like the following: No sewer should 
be used of a smaller diameter than 6 inches (15 centimetres) : a, be- 
cause it will not be safe to adopt a smaller size than 4-inch (10 centi- 
metres) for house-drains, and the sewer must be large enough to 
remove whatever may be delivered by these ; h, because a smaller pipe 
than 6-inch would be less readily ventilated than is desirable ; c, and 
because it is not necessary to adopt a smaller radius than 3 inches (5 
centimetres) to secure a cleansing of the channel by reasonably 
copious flushing. 

"No sewer should be more than 6 inches (15 centimetres) in 
diameter, until it and its branches have accumulated a sufficient flow 
at the hour of greatest use to fill this size to half full, because the 
use of a larger size would be wasteful, and because when a sufficient 
ventilating capacity is secured, as it is in the use of a 6-inch pipe, the 
ventilation becomes less complete as the size increases, leaving a 
larger volume of contained air to be moved by the friction of the 
current, or by extraneous influences, or to be acted upon by changes 
of temperature and volume of flow within the sewer. 

"The size should be increased gradual^, and only so rapidly as 
is made necessary by the filling of the sewer half full at the hour 
of greatest flow. 



182 TEXT-BOOK OF HYGIENE. 

"Every point of the sewer should, by the use of gaskets or other- 
wise, be protected against the intrusion of cement, which, in spite 
of the greatest care, creates a roughness that is -liable to accumulate 
obstructions. 

"The upper end of each branch sewer should be provided with 
a Field's flush-tank of sufficient capacity to secure the thorough 
daily cleansing of so much of the conduit as from its limited flow is 
liable to deposit solid matters by the way. 

"There should be sufficient man-holes, covered by open gratings, 
to admit air for ventilation. If the directions already given are ad- 
hered to, man-holes will not be necessary for cleansing. The use of 
the flush-tank will be a safeguard against deposit. With the system 
of ventilation about to be described, it will suffice to place the man- 
holes at intervals of not less than 1000 feet (305 metres). 

"For the complete ventilation of the sewers it should be made 
compulsory for every householder to make his connection without 
a trap, and to continue his soil-pipe above the roof of the house. 
That is, every house connection should furnish an uninterrupted 
ventilation-channel 4 inches (10 centimetres) in diameter through- 
out its entire length. This is directly the reverse of the system of 
connection that should be adopted in the case of storm-water and 
street-wash sewers. These are foul, and the volume of their contained 
air is too great to be thoroughly ventilated by such appliances. Their 
atmosphere contains too much of the impure gases to make it pru- 
dent to discharge it through house-drains and soil-pipes. With the 
system now described, the flushing would be so constant and com- 
plete and the amount of ventilation furnished, as compared to vol- 
ume of air to be changed, would be so great, that what is popularly 
known as 'sewer-gas' would never exist in any part of the public 
drains. Even the gases produced in the traps and pipes of the house 
itself would be amply rectified, diluted, and removed by the con- 
stant movement of air through the latter. 

"All house connections with the sewers should be through in- 
lets entering in the direction of the flow, and these inlets should be 
funnel-shaped so that their flow may be delivered at the bottom of 
the sewer, and so that they may withdraw the air from its crown; 
that is, the vertical diameter of the inlet at its point of junction 
should be the same as the diameter of the sewer. 

"All changes of direction should be on gradual curves, and, as 
a matter of course, the fall from the head of each branch to the out- 



REMOVAL OF SEWAGE. 183 

let should be continuous. Eeduction of grade within this limit, if 
considerable, should always be gradual. 

"So far as circumstances will allow, the drains should be brought 
together, and they should finally discharge through one or a few main 
outlets. 

"The outlet, if water-locked, should have ample means for the 
admission of fresh air. If open, the mouth should be protected 
against the direct action of the wind. 

"It will be seen that the system of sewerage here described is 
radically different from the usual practice. It is cleaner, is much 
more completely ventilated, and is more exactly suited to the work to 
be performed. It obviates the filthy accumulation of street-manure 
in catch-basins and sewers, and it discharges all that is delivered 
to it at the point of ultimate outlet outside the town before decom- 
position can even begin. If the discharge is of domestic sewage only, 
its solid matter will be consumed by fishes if it is delivered into a 
water-course, and its dissolved material will be taken up by aquatic 
vegetation. 

"The limited quantity and the uniform volume of the sewage, 
together with the absence of dilution by rain-fall, will make its dis- 
posal by agricultural or chemical processes easy and reliable. 

"The cost of construction, as compared with that of the most 
restricted storm-water sewers, will be so small as to bring the im- 
provement within the reach of the smaller communities. 

"In other words, while the system is the best for large cities, 
it is the only one that can be afforded in the case of small towns. 

"Circumstances are occasionally such as to require extensive en- 
gineering works for the removal of storm-water through very deep 
channels. Ordinarily, the removal of storm-water is a very simple 
matter, if we will accept the fact that it is best carried, so far as 
possible, by surface gutters, or, in certain cases, by special con- 
duits, placed near the surface. 

"It is often necessary, in addition to the removal of house-waste, 
to provide for the drainage of the subsoil. This should not be ef- 
fected by open joints in the sewers; because the same opening that 
admits soil-water may, in dry seasons and porous soils, permit the 
escape of sewage matters into the ground, which is always objec- 
tionable. 

"Soil-water drains may be laid in the seme trench with the 
sewers, but preferably, unless they have an independent outlet, on a 
shelf at a higher level. When they discharge into the sewer they 



184 TEXT-BOOK OF HYGIENE. 

should always deliver into its upper part, or into a man-hole at a 
point above the flow-line of the sewage." 6 

The establishment of a system of sewerage presupposes a con- 
stant and abundant supply of water to keep all closets clean and all 
house-drains and street-sewers well flushed. Where this cannot be 
obtained, sewers would be likely to prove greater evils than benefits. 
In such cases one of the methods of removal of excreta before men- 
tioned, either the pail- or earth- closet system, should be adopted. 

The final disposal of sewage is a problem that depends for its 
solution partly upon the agricultural needs of the country around 
the city to be sewered, partly upon the proximity of large bodies of 
water or running streams. When the city is situated upon or near 
large and swiftly-flowing streams, the sewage may be emptied di- 
rectly into the stream without seriously impairing the purity of the 
latter, although the principle of thus disposing of sewage is wrong. 
Dilution, deposition, and oxidation will soon remove all appreciable 
traces of the sewage of even the largest cities. Where, on the other 
hand, the stream is inadequate in size to carry off the sewage, or 
where, as in the Seine and Thames, the current is sluggish, some 
other method of final disposal must be adopted. 

In many cities of Great Britain and the continent of Europe the 
disposal of the sewage by irrigation of cultivated land has been prac- 
ticed for a number of years. The reports upon the working of the 
system are generally favorable, although some sanitarians express 
doubts of the efficiency of the system. In using sewage for the irriga- 
tion of land, two objects are secured: first, the fertilization of the 
land by the manurial constituents of the sewage, and second, the 
purification of the liquid portion by filtration through the soil. The 
organic matters which have been held back by the soil undergo rapid 
oxidation in the presence of air and the bacteria of decay, and are 
converted into plant-food, or into harmless compounds. Sewage irri- 
gation, as practiced in Europe, must make provision for the disposal 
of a very large proportion of water in the sewage (street-wash, storm- 
water), which requires much larger areas of land than would be 
needed if only sewage material proper (water-closet and kitchen-waste) 
was thus to be disposed of. Eecent experiments have shown that the 
purification of sewage is a biological process depending on the action 
of bacteria. 



• The Sewering and Drainage of Cities, Waring, Public Health, vol. v, p. 35. 



REMOVAL OF SEWAGE. 



185 



The more important bacteria found in sewage are 7 : — 

OBLIGATORY ANAEROBES. 

Spirillum rugula, — Gives rise to fecal odor. 
Spirillum amyliferum. — Acts as a vigorous ferment. 
Bacillus butyricus. — Gives rise to much gas. 



FACULTATIVE AXAEROBES, OR AEROBES. 

putrificus coll. — Decomposes albuminous substances, 



■Produces ammonia from 



Bacillus 
with liberation, of ammonia. 

Bacillus mycoidcs. proteus vulgaris. 
nitrogenous matter and denitrification. 

Bacillus fluorescens putridus. — Produces trimethylamine. 

Micrococcus urece. — Converts urea into ammonium carbonate. 

Bacillus lactis aerogenes. — Produces carbon dioxide and hydrogen. 

Bacillus coli communis. — Produces gas, chiefly hydrogen. 

Bacillus subtilis. — Eapidly consumes oxygen. 

Proteus sulphureus. — Produces hydrogen sulphide and mercaptan. 

Bacillus sulphureum. — Liquefies gelatin and casein and produces 
hydrogen sulphide. 

In addition, several other species of bacteria are present in sew- 
age, the action of which is not definitely known. Of disease-producing 
bacteria, bacillus cholerae, bacillus dysenterige (Shiga), bacillus ty- 
phosus, streptococci, and staphylococci have been found. 

These bacteria produce certain changes in the organic matter, 
resolving the highly complex organic molecules into simple inorganic 
compounds. 

The changes taking place in sewage are as follows (Rideal) : — 



Table XXVII. 



Initial 
Transient aerobic changes 
by the oxygen of the 
water supply rapidly 
passing to : 

First Stage 

Anerobic liquefaction and 
preparation by hydroly- 



Substances dealt with 



Urea, Ammonia, and easily 
decomposable matters. 



Albuminous matters . Cel- 
lulose and fibre fats. 



Characteristic Products 



Soluble nitrogenous com- 
pounds. Phenol deriva- 
tives. Gases. Ammo- 
nia. 



Sewage and the Bacterial Purification of Sewage. S. Rideal, 1901. 



186 



TEXT-BOOK OF HYGIENE. 



Table XXVII.— ( Continued). 



Second Stage 
Semi-auerobic breaking Amido compounds 



Substances dealt with 



down of the intermedi- 
ate dissolved bodies. 

Third Stage 
Complete aeration : nitri- 
fication. 



acids, 
dues. 



Fatty 
Dissolved resi- 
Phenolic bodies. 



Ammonia and carbona- 
ceous residues. 



Characteristic Products 



Ammonia. Nitrites. Gases. 



Carbon dioxide, water, and 
nitrates. 



Based on these principles, various methods of purification of 
sewage have been adopted. 

1. Broad Irrigation. — This method is defined by the Koyal Com- 
mission on Metropolitan Sewage Discharge as "the distribution of 
sewage over a large surface of ordinary agricultural land, having in 
view a maximum growth of vegetation (consistent with due purifi- 
cation) for the amount of sewage supplied." 

2. Irrigation with Copious TJnderdrainage. — This method is de- 
fined as "the concentration of sewage, at short intervals, on an area 
of specially-chosen porous ground, as small as will absorb and cleanse 
it ; not excluding vegetation, but making the produce of secondary im- 
portance." 

3. Sedimentation or Chemical Precipitation, Followed by Broad 
Irrigation or Filtration. — In this system the sewage is precipitated 
by lime or iron sulphate, the precipitate allowed to settle, and the 
supernatent liquid is distributed over large areas of land or made to 
pass through sand filters. The latter method is employed successfully 
in Worcester, Mass. However, the difficulty of disposing of the sedi- 
ment, or "sludge," is quite serious and greatly impairs the utility of 
the system. 

4. Sterilization by Heat and Disinfection. — These methods, while 
no doubt the most efficient, are not practical on a large scale. 

5. Bacterial Purification. — This system, otherwise known as the 
"septic tank" method, is the outcome of a series of experiments made 
since 1865, which proved that the disintegration and final purifica- 
tion of sewage are due to the action of micro-organisms. In 1865, Dr. 
A. Mueller wrote: "The contents of sewage are chiefly of organic 
origin, and in consequence of this an active process of decomposition 
takes place in sewage, through which the organic matters are gradu- 
ally dissolved into mineral matters, or, in short, are mineralized, and 



REMOVAL OF SEWAGE. 187 

thus become fit to serve as food for plants. To the superficial observer 
this process appears to be a chemical self-reduction; in reality, how- 
ever, it is chiefly a process of digestion, in which the various — mostly 
microscopically small — animal and vegetable organisms utilize the 
organically fixed power for their life purposes." 

The "septic tank" is merely a large cesspool in which the sew- 
age undergoes putrefactive changes brought about by the activity of 
anaerobic bacteria. 

"The septic or bacterial tank may be built of concrete, brick, 
masonry, or wood, and it may be covered or not, though a light cov- 
ering of boards, to prevent the wind and rain breaking up the sur- 
face scum, may be advisable. An airtight covering is necessary only 
when the tank is located in a portion of the community where its 
odors would become a nuisance. The tanks should be large enough to 
hold the sewage of 2000 persons for one day, or about 55,000 gallons. 
In the most approved tanks there are two compartments, the first 
being about ten feet deep by seven feet long and eighteen feet wide 
and known as the 'grit chamber/ as it is designed to receive the grit 
and heavier settlings from the sewage. Into this the crude sewage is 
led by two inlet pipes, which discharge about five feet beneath the 
surface, so as not to disturb either the surface crust or the settled 
sediment. From this first chamber the contents flow through sub- 
merged openings in the partition wall into the second compartment, 
which is about seven feet deep, sixty-five feet long, and of the same 
width as the first. The flow is maintained at a rate to take twenty- 
four hours from entrance to exit. The effluent is brownish yellow 
in color and more or less offensive in odor. 

"In the septic tank, as in the cesspool, the anaerobic or putre- 
factive bacteria are the active agents, and so energetic are they on a 
warm day that the contents of the tank seem fairly to boil, though, of 
course, the temperature is but slightly above that of the surrounding 
air. The microbes penetrate the solids floating in the sewage, and 
their gaseous products accumulate in such volume as to carry the 
solids to the surface of the tankage, sometimes with sufficient force to 
project them through the overlying crust. It is this and the escap- 
ing gas which give the boiling appearance on a hot day. The whole 
mass is very actively at 'work/ and the process is identical with 
that which takes place in a jar of 'working' apple-butter or pre- 
serves insufficiently cooked or insufficiently supplied with cane sugar. 
In short, the process is one of fermentation, and by it 40 to 60 per 
cent, of the organic matter is removed, while over the bottom of the 



188 TEXTBOOK OF HYGIENE. 

tank accumulates the small percentage of 'ash' or mineral matter 
originally combined in the sewage, amounting to a deposit of some- 
thing over a foot per year. The gas generated is rich in hydrocarbons 
and may be used for fuel or illumination." 

From the "septic tank" the sewage, which is now completely 
hydrolyzed, is passed through beds of either broken brick, cinders, 
coke, or stone, the so-called "contact beds," or sand, to which the term 
"filter-bed " is applied. While passing through these beds, the re- 
maining organic impurities are oxidized by the aerobic bacteria. 

The rate of nitration is about 500,000 gallons per acre per day. 

The resulting effluent is clear, colorless, practically odorless, and 
practically free from sewage bacteria. Such an effluent may be safely 
emptied into a stream without danger of polluting it. 

The "septic tank" treatment of sewage has been also employed 
for the purification of the sewage on a small scale. The following 
adaptation is recommended by the Illinois State Board of Health 8 : — 

"This plant consists of two tanks, the first the septic tank proper ; 
the second, a discharging tank. The septic tank is, in construction, 
practically a cistern 4 feet in diameter and about 3 feet deep. The 
sewage from the house enters this tank through a lightly trapped 
pipe, the flow from the ordinary household preventing the back-flow 
of air. Across the center of the tank is a wall, which divides it into 
two chambers of equal size. The height of this wall is exactly to the 
point of outflow. 

"The sewage from the house enters the first chamber of the septic 
tank with considerable force, causing some disturbance of the con- 
tents. The flow over the dividing wall into the second chamber, how- 
ever, is even and slow, so that the contents of the second chamber are 
not disturbed, and the flocculent matter settles readily to the bottom. 

"The bacterial action on the contents of this tank is often so 
complete that there is no appreciable residue or sludge, and in this 
case the tank will rarely if ever have to be cleaned out. In some 
instances, however, the tank will require occasional cleaning. The 
sludge from a well-constructed tank is not offensive, and may be dis- 
posed of without difficulty. 

"The sewage is carried into the discharging chamber (which is 
a cistern 6 feet in diameter and about 4 feet in depth), through a 
deeply trapped pipe. The second or discharging tank should be of 
sufficient size to hold the overflow from the septic tank for a period 



8 Bull. No. 2, 1906. 



REMOVAL OF SEWAGE. 189 

of 12 to 24 hours. At the bottom of the discharging tank is an 
automatic siphon, which is opened automatically when the effluent 
reaches a certain height in the tank or chamber — a height of about 
2y 2 feet. Through this siphon the contents of the chamber will pass 
in a very few moments, at which time the siphon will automatically 
close and the chamber will again refill. 

"From the siphon, a pipe conducts the effluent to the place of 
discharge, usually on a lawn, or in a pasture or field. 

"The effluent is usually entirely without odor and is inoffensive 
in every way. It may be discharged upon a lawn, provided the lawn 
is well under-tiled and drained, or it may be emptied into any stream, 
provided the water from the stream is not used for drinking purposes. 
While it is true that raw sewage is frequently directed into streams 
whose water is used for domestic purposes, it is contrary to the policy 
of the State Board of Health to sanction even the discharge of this 
comparatively harmless effluent into such streams." 

A number of small septic tank disposal plants have been con- 
structed in the vicinity of Wilmington, Del., for the disposal of the 
sewage from large residences. The results have proved quite satis- 
factory. 

Garbage. — By garbage is meant refuse from the kitchen. This 
should be collected in air-tight receptacles and frequently removed for 
final disposal. The latter may be effected either by feeding the 
garbage to hogs or cremation. While cremation is the more expen- 
sive of the two processes, it is also the more sanitary and should be 
preferred on that account. 



QUESTIONS TO CHAPTER V. 

REMOVAL OF SEWAGE. 

Why must arrangements be made in all large communities for the re- 
moval of sewage? To what do the organic constituents of sewage give rise, 
and what is the effect upon health of the continued inhalation of these prod- 
ucts? How else may the impregnation of the soil with sewage endanger 
health? What, then, is the object of any system of sewage removal? What 
will likely govern the choice and adoption of a sewage-removal system by any 
community ? 

What different systems are in use at the present time? Which of these 
is the worst and most unsanitary? In case the privy system is to be con- 
sidered, what conditions should be insisted upon? How may a privy be ven- 
tilated? Why should a privy not be located in a cellar nor too near the house? 
What substances may be used to deodorize the contents of privy-vaults,, and 
how? Are deodorizers always disinfectants, and is the danger necessarily 
removed when the odor is destroyed? How often should privy-vaults be 
emptied? How may this be done without offense to the senses? What are 
the grave objections to the midden or shallow-pit system, and to digging the 
vault or cess-pool to the level of the ground-water ? 

What is meant by the Rochdale or pail-closet system? What are some 
of its advantages? What can be said of its efficacy for large communities and 
for the economy of administration? What is an earth-closet, and upon what 
does its efficacy depend? What are some of its advantages? 

Describe the pneumatic system of Liernur. Has it apparently been satis- 
factory in its workings? What other systems have employed the pneumatic 
principle, and with what success? 

What do we mean by the water-carriage system of sewerage ? What two 
systems are embraced under this head? What is the distinction between the 
two? Which is in most common use? What must be the size of the sewers in 
the combined system, and what are the consequent objections? Why does 
the separate system seem the better? Describe the latter in detail. What 
governs the size of the drains in the separate system? How is this system 
kept clean and free from obstruction? How is it to be ventilated? How does 
it differ in this respect from the combined system? What are some of the 
especial points to be observed in the construction ? What may be said as to 
cost of construction and as to the ultimate disposal of the sewage? Why 
should sewers not be employed to drain the subsoil? How may this be done? 

What does the establishment of a sewerage system presuppose? If 
plenty of water cannot be had, what system of sewage removal should be 
adopted ? 

(190) 



QUESTIONS TO CHAPTER V. 191 

In what way may we finally dispose of the sewage? What are the objec- 
tions to discharging it into running streams? How will it be finally disposed 
of in such a stream? What is meant by the irrigation, the sub-irrigation, and 
the filtration methods? What becomes of the organic matter of the sewage 
in each case? What of the sewage water? What sort of soil is needed for 
the irrigation method? What can be said of the disposal of sewage and 
garbage by cremation? What chemicals are used for the precipitation of 
sewage? What action have bacteria on sewage? What is the septic tank 
method of purification of sewage? How may this method be used on a small 
scale? How should garbage be disposed of? 



CHAPTER VI. 

CONSTRUCTION CF HABITATIONS. 

The importance of observing the principles of hygiene in the 
construction of habitations for human beings is not sufficiently appre- 
ciated by the pubic. Architects and builders themselves have not 
kept pace with the sanitarian in the study of the conditions necessary 
to be observed in building a dwelling-house which shall answer the 
requirements of sanitary science. 

In an investigation conducted by Dr. Yillerme 1 it was found that 
in France, from 1821 to 1827, of the inhabitants of arrondissements 
containing 7 per cent, of badly-constructed dwellings, 1 person out 
of every 72 died; of the inhabitants of arrondissements containing 
22 per cent, of badly-constructed dwellings, 1 out of 65 died; while 
of the inhabitants of arrondissements containing 38 per cent, of 
badly-constructed dwellings, 1 out of every 45 died. 

Inseparab'e from the question of the defective construction of 
dwellings is that of overcrowding in cities, because the most crowded 
portions of a city are at the same time those in which the construction 
of dwellings is most defective from a hygienic standpoint. The fol- 
lowing tables show the relations of the death-rate to density of popu- 
lation in various large cities of Europe, and also the relations between 
overcrowding in dwellings and the mortality from contagious dis- 
eases : — 



Table XXVIII. 

RELATION OF DEATH-RATE TO DENSITY OF POPULATION. 



City 


Mean Number of Inhab- 
itants to each house 


Average Dea'h-rate per 
1000 Inhabitants 


London 


8 
32 
35 
52 
55 


24 


Berlin 


25 


Paris 


28 


St. Petersburg 


41 


Vienna 


47 







Quoted in Realeneyclopaedia d. ges. Heilk., Bd. ii, 71. 
(192) 



CONSTRUCTION OF HABITATIONS. 193 

In Glasgow, the death-rate in apartments with 1.31 occupants 
is 21.7 per 1000, while in apartments with 2.05 occupants the rate is 
28.6 per 1000. 

In Buda-Pesth, in 1872-73, it was found that out of every 100 
deaths from all causes there were, from contagious diseases: — 

20 deaths in dwellings with 1 to 2 persons in each room. 

29 " " " " 3 " 5 " " " " 

09 a a a " fi " 10 " " " " 

79 " " " " over 10 " " " 

Dr. Jose A. de los Rios gives the following statistics, bearing 
upon the mortality of cholera, in relation to the number of persons 
occupying one room when attacked by it: — 

Of 10,000 persons attacked by cholera, and living 1 person to the 
room, 68 died. 

Of 10,000 persons attacked by cholera, from 1 to 2 to the room, 
131 died. 

Of 10,000 persons attacked by cholera, living 2 to 4 to the room, 
219 died. 

Of 10,000 persons attacked by cholera, living 4 or more to the 
room, 327 died. 

These figures show very clearly the vital importance of the appli- 
cation of sanitary laws in the construction and occupation of dwell- 
ings. 

The direct relation of overcrowding to pulmonary tuberculosis 
has been firmly established by recent statistics. Not only do the 
absence of light, air, and sunshine usually found in overcrowded tene- 
ments favor the long life of the tubercle bacillus, but the aggregation 
of people, many of whom are tuberculous, tends to a rapid dissemi- 
nation of the disease. The tuberculosis problem will never be satis- 
factorily solved so long as the housing of the poor will remain in the 
wretched condition in which we see it to-day in large cities. 

Another curious and suggestive point is presented by some statis- 
tical researches on the mortality of Berlin, in regard to the death- 
rate among persons living in different stories of houses. It was 
found, for example, that the mortality in fourth-story dwellings is 
higher than in the lower stories. Even basement dwellings furnish 
a lower death-rate. Still-births, especially, occur in a larger propor- 
tion among the occupants of the upper stories of houses. This may 
be explained by the unfavorable effects of frequent stair-climbing, 
especially on pregnant women. 

13 



194 



TEXTBOOK OF HYGIENE. 



It is in the death-rate among young children that the effects of 
overcrowding and unsanitary construction of dwellings are especially 
manifest. The mortality returns from all the large cities of the world 
give mournful evidences of this every summer. 

The researches of Dr. H. I. Bowditch upon soil-wetness, to which 
reference has already been made in a previous chapter, show conclu- 
sively that persons living in houses situated upon or near land habit- 
ually or excessively wet, are especially prone to be attacked by pul- 
monary consumption. Dr. Buchanan 2 has corroborated the truth of 
Dr. Bowditch's observations by showing, from the records of a num- 
ber of cities and towns of Great Britain, that, with the introduction 
of a good drainage system, bringing about a depression and uniformity 
of level of the ground-water, the mortality from consumption and 
other diseases very markedly diminished. The following table, show- 
ing the proportionate amount of this diminution, is abridged from the 
official reports 3 : — 

Table XXIX. 

RESULTS OF SANITARY WORK. 



Name of Place. 



Banbury . . 

Cardiff 

Croydon . . . 

Dover 

Ely 

Leicester . . . 
Macclesfield 
Merthyr . . . 
Newport . . 

Rugby 

Salisbury . . 
Warwick . . 



10,238 
33,954 
30,229 
23,108 

7,847 
68,056 
27,475 
52,778 
24,756 
7,818 
9,030 
10,570 



JO ltl 

^- O I'M 

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bo p. ©'-5 c 



<$ 



c3^ m 



23.4 
33.2 
23 7 
22 6 
23.9 
26 4 
29.8 
33.2 
31.8 
19.1 
27.5 
22.7 



J O I OS 

© a> o!> 
£t»©° 

©.■S 2 a 



20.5 
22.6 
18.6 
20.9 
20.5 
25.2 
23.7 
26.2 
21.6 
18.6 
21.9 
21.0 



121 

32 

22 

7 
14 

4£ 
20 
18 
32 

2} 
20 



© o 



© ojs 
© >> ' 



48 
40 
63 
36 
56 
48 
48 
60 
36 
10 
75 
52 



41 
17 
17 
20 
47 
32 
31 
11 
32 
43 
40 
19 



The following must be taken into account in building a house in 
accordance with sanitary principles: — 

I. SITE. 



The building-site should be protected against violent winds, 
although a free circulation of air all around the house must be se- 



2 Ninth and Tenth Reports of the medical officer to the Privy Council. 

3 Sanitary Engineering, Baldwin Latham, p. 2. Chicago, 1877. 



CHARACTER OF THE SOIL. 195 

cured. Close proximity to cemeteries, marshes, and injurious manu- 
facturing establishments or industries must be avoided if possible. A 
requisite of the highest importance is the ability to command an 
abundant supply of pure water for drinking and other purposes. A 
neglect of this precaution will be sure to result to the serious incon- 
venience, if not detriment, of the occupants of the house. 

II. CHARACTER OF THE SOIL. 

The soil should be porous and free from decomposing animal or 
vegetable remains, or excreta of man or animals. It should be freely 
permeable to air and water, and the highest level of the ground-water 
should never approach nearer than 3 metres to the surface. The fluc- 
tuations of the ground-water level should be limited. In this 
connection, attention is again called to the aphorism of Dr. De- 
Chaumont. 4 

It is impossible to say positively that any kind of soil is either 
healthy or unhealthy, merely from a knowledge of its geological char- 
acters. The accidental modifying conditions above referred to, viz., 
organic impurities, moisture, the level and fluctuations of the ground- 
water, are of much greater importance than mere geological formation. 
The late Dr. Parkes, however, regarded the geological structure and 
conformation as of no little importance, and summarized the sani- 
tary relations of soils, variously constituted, as follows 5 : — 

"1. The Granitic, Metamorphic, and Trap Rocks. — Sites on these 
formations are usually healthy; the slope is great, water runs off 
readily; the air is comparatively dry; vegetation is not excessive; 
marshes and malaria are comparatively infrequent; and few im- 
purities pass into the drinking-water. 

"When these rocks have been weathered and disintegrated they 
are supposed to be unhealthy. Such soil is absorbent of water; and 
the disintegrated granite of Hong Kong is said to be rapidly per- 
meated by a fungus; but evidence as to the effect of disintegrated 
granite or trap is really wanting. 

"In Brazil the syenite becomes rapidly coated with a dark sub- 
stance and looks like plumbago, and the Indians believe this gives 
rise to 'calentura' or fevers. The dark granitoid, or metamorphic trap, 
or hornblendic rocks in Mysore are also said to cause periodic fevers ; 
and iron hornblende, especially, was confirmed by Dr. Heyne, of 



"Chapter iv, p. 130. 

5 Practical Hygiene fith ed., vol. i, p. 359. 



196 TEXT-BOOK OF HYGIENE. 

Madras, to be dangerous in this respect. But the observations of 
Richter on similar rocks in Saxony, and the fact that stations on the 
lower spurs of the Himalayas on such rocks are quite healthy, negative 
Heyne's opinion. 

" 2. The Clay Slate. — These rocks precisely resemble the granite 
and granitoid formations in their effects on health. They have usu- 
ally much slope, are very impermeable, vegetation is scanty, and 
nothing is added to air or drinking-water. 

"They are consequently healthy. Water, however, is often scarce, 
and as to the granite districts, there are swollen brooks during rain, 
and dry water-courses at other times, swelling rapidly after rains. 

" 3. The Limestone and Magnesium Limestone Rocks. — These so 
far resemble the former that there is a good deal of slope and rapid 
passing off of water. Marshes, however, are more common, and may 
exist at great heights. In that case, the marsh is probably fed with 
water from some of the large cavities which in the course of ages 
become hollowed out in the limestone rocks by the carbonic acid in the 
rain, and form reservoirs of w T ater. 

"The drinking-water is hard, sparkling, and clear. Of the 
various kinds of limestone, the hard oolite is best and magnesium is 
worst; and it is desirable not to put stations on magnesium limestone 
if it can be avoided. 

"4. The Chalk. — The chalk, when mixed with clay, and perme- 
able, forms a very healthy soil. The air is pure, and the water, 
though charged with calcium carbonate, is clear, sparkling, and 
pleasant. Goitre is not near'y so common, nor apparently calculus, 
as in the limestone districts. 

"If the chalk be marly, it becomes impermeable, and is then 
often damp and cold. The lower parts of the chalk, which are 
underlaid by gault clay, and which also receive the drainage of the 
parts above, are often very malarious ; and in America some of the 
most marshy districts are in the chalk. 

"5. The Sandstones. — The permeable sandstones are very healthy ; 
both soil and air are dry; the drinking-water is, however, sometimes 
impure. If the sand be mixed with much clay, or if clay underlies 
a shallow sand-rock, the site is sometimes damp. 

"The hard millstone-grit formations are very healthy, and their 
conditions resemble those of granite. 

" 6. Gravels of any depth are always healthy, except when they 
are much below the general surface, and water rises through them. 
Gravel hillocks are the healthiest of all sites, and the water, which 



CHARACTER OF THE SOIL. 197 

often flows out in springs near the base, being held up by the under- 
lying clay, is very pure. 

" 7. Sands. — There are both healthy and unhealthy sands. The 
healthy are the pure sands, which contain no organic matter, and are 
of considerable depth. The air is pure, and so is often the drinking- 
water. Sometimes the drinking-water contains enough iron to be- 
come hard, and even chalybeate. The unhealthy sands are those 
which, like the subsoil of the Landes, in southwest France, are com- 
posed of silicious particles (and some iron) he'd together by a vege- 
table sediment. 

"In other cases sand is unhealthy from underlying clay or 
laterite near the surface, or from being so placed that water rises 
through its permeable soil from higher levels. Water may then be 
found within 3 or 4 feet of the surface; and in this case the sand 
is unhealthy and often malarious. Impurities are retained in it and 
effluvia traverse it. 

"In a third class of cases the sands are unhealthy because they 
contain soluble mineral matter. Many sands (as, for example, in 
the Punjab) contain magnesium carbonate and lime-salts, as well as 
salts of the alkalies. The drinking-water may thus contain large 
quantities of sodium chloride, sodium carbonate, and even lime and 
magnesian salts and iron. Without examination of the water it is 
impossible to detect these points. 

"8. Clay, Dense Marls, and Alluvial Soils Generally. — These 
are always regarded with suspicion. Water neither runs off nor runs 
through; the air is moist; marshes are common; the composition of 
the water varies, but it is often impure with lime and soda salts. In 
alluvial soils there are often alterations of thin strata of sand, and 
sandy, impermeable clay. Much vegetable matter is often mixed with 
this, and air and water are both impure. 

"The deltas of great rivers present these alluvial characters in 
the highest degree, and should not be chosen for sites. If they must 
be taken, only the most thorough drainage can make them healthy. 
It is astonishing, however, what good can be effected by the drain- 
age of even a small area, quite insufficient to affect the general atmos- 
phere of the place; this shows that it is the local dampness and the 
effluvia which are the most hurtful. 

"9. Cultivated Soils. — Well-cultivated soils are often healthy; 
nor at present has it been proved that the use of manure is hurtful. 
Irrigated lands, and especially rice-fields, which not only give a great 
surface for evaporation, but also send up organic matter into the air, 



198 TEXT-BOOK OF HYGIENE. 

are hurtful. In Northern Italy, where there is a very perfect sys- 
tem of irrigation, the rice-grounds are ordered to be kept 14 kilo- 
metres (8.7 miles) from the chief cities, 9 kilometres (5.6 miles) 
from the lesser cities and the forts, and 1 kilometre (1094 yards) from 
the smaller towns. In the rice countries of India [and America] 
this point should not be overlooked." 

Where a wet, impermeable, or impure soil must, of necessity, 
be chosen as a building-site, it should be thoroughly drained. The 
minimum depth at which drains are laid should be not less than iy 2 
metres below the floor of the cellar or basement. Such a soil should 
be covered with a thick, impervious layer of asphaltum or similar 
cement under the house, in order to prevent the aspiration of the pol- 
luted ground-air into the building. 

It is a frequent custom in cities to fill in irregularities of the 
building-site with street-sweepings and garbage, which always con- 
tain large quantities of decomposing organic matters. This is a 
gross violation of the plainest principles of hygiene. It is almost 
equally reprehensible to use such decaying or putrefying organic mate- 
rial for the purpose of grading streets or sidewalks in cities and 
towns. 6 It should be the constant endeavor of all sanitary authorities 
to prevent pollution of the soil as much as possible in villages, 
towns ; and cities. 

Where houses are built on the declivity of a hill, the upper wall 
should not be built directly against the ground, as it would tend to 
keep the wall damp. A vacant space should be left between the wall 
and the ground to permit free access of air and light. 

In addition to, or in default of, drainage, the dryness of soil 
can be promoted by rapidly-growing plants, which absorb water from 
the soil and give it out to the air. The sunflower and the eucalyptus 
tree are the most available for this purpose. 

III. THE MATERIAL OF WHICH THE HOUSE IS BUILT. 

The nature of the most appropriate building material depends 
upon so many collateral circumstances that definite rules cannot be 

'During the very fatal epidemic of yellow fever in New Orleans, in 1878, 
it was ascertained that a contractor for street-work used the garbage and 
street-scrapings to grade the bed of the streets. Even though in this case it 
may not have intensified the epidemic in these localities, the practice is so 
contrary to the simplest sanitary laws that it should nowhere be tolerated. 
The author is aware, however, that the "made-ground" of nearly every city 
in this country is composed largely of just such material. All sanitarians 
should protest against a continuance of this pernicious practice. 



MATERIAL OF WHICH THE HOUSE IS BUILT. 199 

laid down. As a general rule, moderately hard burned brick is the 
most serviceable and available material. It is easily permeable by the 
air, and so permits natural ventilation through the walls, unless this is 
prevented by other means. It does not absorb and hold water readily ; 
hence, damp wails are infrequent if brick is used. It is probably, of 
ail building material, the most durable. On account of its porosity 
a brick wall is a poor conductor of heat. It therefore prevents the 
rapid cooling of a room in cold weather, and likewise retards the 
heating of the inside air from without in summer. Another very 
great advantage is its resistance to a very high degree of heat, brick 
being probably more nearly fire-proof than any other building mate- 
rial. 

In hot climates light wooden buildings are advantageous because 
they cool off very rapidly after the sun has disappeared. On account 
of the numerous joints and fissures in a frame building, natural ven- 
tilation goes on very readily and to a considerable extent. 

Next to brick, granite, marble, and sandstone are the most ser- 
viceable building materials. Very porous sandstone is, however, not 
very durable in cold climates, as the stone absorbs large quantities of 
water, which, in consequence of the expansion accompanying the act 
of freezing, produces a gradual but progressive disintegration. Ee- 
cently, concrete has been successfully employed as a building material. 

The application of paint to the walls, either within or without, 
almost completely checks the transpiration of air through the walls, 
thus limiting natural ventilation. Calcimining, on the other hand, 
offers very little obstruction to the passage of air. Wall-paper is 
about midway between paint and lime-coating in its obstructive effect 
on atmospheric transpiration. 

Newly-built houses should not be occupied until the walls have 
become dry. Moisture in the walls is probably a not infrequent source 
of ill health; it offers favorable conditions for the development of 
fungi (possibly disease-germs), and by filling up the pores of the 
material of which the walls are composed, prevents the free transpira- 
tion of air through them. 

Moisture of the walls is sometimes due to the ascent of the water 
from the soil by capillary attraction. This can be prevented by inter- 
posing an impervious layer of slate in the foundation- wall. 

Where the moisture is due to the rain beating against the out- 
side walls, and thus saturating them if composed of porous materials. 
a thorough external coating of impervious paint will prove a good 
remedy. 



!00 TEXT-BOOK OF HYGIENE. 



IV. INTERIOR ARRANGEMENTS. 



A. Size of Rooms, and Ventilating and Heating Arrangements. — 

The rooms in dwelling-houses should never be under 2 1 / 2 metres in 
height from floor to ceiling. In sleeping-rooms the initial air-space 
should never be less than 35 cubic metres for adults, and 25 cubic 
metres for children under 10 years of age. Provision must be made 
for changing this air sufficiently often to maintain it at its standard 
of purity; i.e., less than 7 parts of carbon dioxide per 10,000. The 
details for accomplishing this will vary with the architect's designs, 
the material of which the house is constructed, the climate, and the 
season. The principles laid down in the section on ventilation 
(Chapter 1) should be adhered to. In cold weather the air should 
be warmed, either before its entrance into the room or afterward, by 
stove or fire-place. Galton's jacketed stove, or fire-place, seems to 
answer this purpose admirably. The details of the heating apparatus 
must be left to individual taste, or other circumstances. It may be 
noted, however, in passing, that the prevailing method of heating 
houses by means of hot air is objectionable for various reasons: 
partly, because the air is usually too dry to be comfortable to the 
respiratory organs ; partly, because organic matter is frequently pres- 
ent in large proportions, and gives the air an offensive odor when the 
degree of heat is high enough to scorch the organic matter. Both these 
objections are, however, removable; the first by keeping a vessel of 
water constantly in the furnace, so that the hot air can take up a suffi- 
cient proportion of vapor in passing through, and, the second, by 
having the furnace made large enough so that the temperature need 
never be raised to a very high degree. Heating by hot water or 
steam is preferable to the hot-air furnace. Both of these methods 
are, however, more expensive to install. 

Where special ventilating arrangements are necessary, air-inlets 
may be inserted at appropriate points in the walls of the room, fac- 
ing toward the air. A simple arrangement is that known as the 
Bury Ventilator, shown in Figs. 14 and 15. It consists of a wooden 
block interposed between the bottom of the lower window-sash and 
the window-frame. The air passes into the room through the open- 
ings in the block, as shown in the illustration. The separation of the 
upper and lower sashes, when the ventilator is in place, also adds 
to the efficiency of the ventilation, as the air passes in through the 
space so formed. 



INTERIOR ARRANGEMENTS. 



201 



A cheaper ventilator can be made by simply tacking a strip 
of canvas, binders' board, or manilla paper, 20 to 25 centimetres wide, 
across the lower portion of the window-frame, and then raising the 




Fig. 14. 



Fig. 11 



Fig. 14. — a, a, Sash, b, b, Window-jambs, c, c, Window-sill. This 
cut represents the view from within the Bury Ventilator, in operation. 
It is broken away at one end to show the sash raised above the outer 
holes to admit the air. 

Fig. 15. — a, a, Sash. This cut represents the view from without 
the Bury Ventilator, in operation. The sash is broken away to show 
the ventilator behind, with the fresh air passing in. 



sash 10 to 15 centimetres. The air will pass in under the lower and 
between the lower and upper sashes and pass upward toward the ceil- 
ing and then gradually diffuse itself through the room. In summer 



'20-2 



TK XT-BOOK OF HYGIEN 



a counter-opening may be obtained for the escape of foul air by low- 
ering the upner sash, while in winter a stove or fire-place will furnish 



a good exit. 




Fig. 16 shows the probable course of the air-currents in a room 
ventilated by means of a fresh-air inlet near the ceiling and an open 
fire-place. A is the inlet; C, the fire-place ; G, the floor; F, ceiling; 
E E, flues. 



INTERIOR ARRANGEMENTS. 203 

B. Internal Wall-coating. — A point of considerable importance 
in the outfitting of dwelling-houses is the material used for coating 
or decorating the inside of the walls. Green paint and green-colored 
wall-papers should be rejected. The reason for avoiding this color 
is the following: Bright-green pigments and dyes are largely com- 
posed of some compound of arsenic, which becomes detached from the 
wall or paper when dry and, being inhaled, produces a train of 
symptoms which have been recognized as chronic arsenical poisoning. 
Many cases have been reported in which serious and even fatal poison- 
ing has been produced in this way. 7 It would be advisable, therefore, 
to discard all bright-green tints in paints and ornamental paper- 
hangings. 

C. Lighting. — Provision should be made in all dwelling-houses 
for an abundant supply of sunlight. Every room should have at least 
one window opening directly to the sun. It is not sufficient to give an 
ample window-space, which should be in the proportion of one to five 
or six of floor-space, but the immediate surroundings of the house 
must be taken into account. Thus, close proximity of other buildings, 
or of trees, may prevent sufficient light entering a room, although 
the window-space may be in excess of that required under ordinary 
circumstances. 

Some form of artificial light will also be needed in all dwell- 
ings. Certain dangers are necessary accompaniments of all avail- 
able methods of artificial illumination. The danger from fire is, of 
course, the most serious. This danger is probably least where candles 
are used, and greatest where the more volatile oils (kerosene, gasolene) 
are employed. The use of candles results in pollution of the air by 
carbon dioxide and other products of combustion to a greater degree 
than when other illuminating agents are used; they also give out 
a larger amount of heat in proportion to their power of illumina- 
tion. Kerosene gives a good light when burned in a proper lamp, 
and is cheap, but the dangers from explosion and fire are consider- 
able. The danger from explosion can be greatly reduced by always 
keeping the lamp filled nearly to the top, and never filling it near a 
light or fire. The danger of exp^sion is increased when the chimney 
of the lamp is broken, as then the temperature of the metal collar, 
by which the burner is fastened to the lamp, is rapidly raised 8 and 
the oil vaporized. If, at the same time, the lamp is only partially 



'Arsenic in Certain Green Colors, F. W. Draper. Third Annual Report 
Mass. State Board of Health, 1872, pp. 18-57. 

8 H. B. Baker, in Report Mich. State Board of Health, 1876, p. 48. 



204 TEXT-BOOK OF HYGIENE. 

filled with oil, the space above it is occupied by an explosive mixture 
of air and the vapor of the oil. If this is heated to a sufficient degree 
an explosion will take place. 9 

The use of coal-gas is probably attended by less danger than the 
lighter oils, but by more than other means of illumination. In addi- 
tion to the dangers from fire and explosions, which are inevitable ac- 
companiments of defects in the fixtures, the escaping gas is itself 
exceedingly poisonous from the large amount of carbon monoxide it 
contains. It is, in fact, a very frequent occurrence in large cities that 
persons are killed by the inhalation of gas which has escaped from 
the fixtures or was allowed to escape from the burner through igno- 
rance. That variety of illuminating gas known as "water-gas" is more 
dangerous to inhale than coal-gas owing to the larger proportion of 
carbon monoxide contained in it. Eecent experiments by T. A. Maass 
indicate that the toxic action of illuminating gas is due in part to 
some factor aside from the carbonic oxide, as it is so much more toxic 
than CO alone. The "natural gas" used as a fuel and illuminant in 
some places in the United States is especially dangerous from the 
total absence of odor. The gas may escape in large quantity and fail 
to give notice of its presence except by an explosion, if ignited, or 
by producing asphyxia in those who incautiously venture into the 
air permeated by it. The slight but continuous escape of gas from 
defective or leaky fixtures may produce a grave form of anemia. 
Chronic CO poisoning is probably of more frequent occurrence in 
cities than is generally suspected. 

The electric light (Edison's incandescent system) is probably 
open to less objection on the score of danger than any other of the 
illuminating systems mentioned. There is no trustworthy evidence 
that the electric light has any unfavorable influence on the vision, 
although Eegnault supposed it would have a bad effect upon the 
ocular humors on account of the large proportion of the violet and 
ultra-violet rays it contained. In order to remove this objection 
Bouchardat advised the wearing of yellow glasses by those compelled 
to use this light for close work. The advantages of the incandescent 
light, besides the brilliant white light it gives, are that it is steady 
and does not produce any heat, nor does it pollute the air with car- 
bon dioxide and other products of combustion. Professor von Petten- 
kofer has shown experimentally that the pollution of the air by 
the products of combustion is very much greater when gas is used 



•See an instructive paper by Prof. R. C. Kedzie, in Report Mich. State 
Board of Health for 1877, p. 71 et seq. 



HOUSE-DRAINAGE. 205 

than where the electric light is employed. The electric arc-lights are 
extremely dangerous on account of the high potential maintained in 
the wires, and the difficulty of thoroughly insulating the latter. Many 
deaths have occurred from this source, and unless a method is dis- 
covered and adopted by which the voltage of the arc-light current can 
be greatly diminished without decreasing the efficiency of the light, 
this method of lighting must soon be given up in cities, owing to its 
danger, not only to those directly brought in contact with the conduc- 
tors, but to others who may indirectly get in the way of the errant 
current. 

In writing, sewing, reading, or other work requiring a constant 
use of accurate vision, the light, whether natural or artificial, should 
fall upon the object from above and on the left side. Hence, windows 
and burners should be at least the height of the shoulder and to the 
left of the person using the light. 

Increased ventilation facilities must be provided where artificial 
light (except the electric light) is used to any extent. It has been 
calculated that for every lighted gas-burner 12 to 15 cubic metres of 
fresh air per hour must be furnished in addition to the amount or- 
dinarily required in order to maintain the air of the room at the 
standard of purity. 

V. WATER=SUPPLY. 

The water-supply of a dwelling-house should be plentiful for 
all requirements, and its distribution should be so arranged that the 
supply for every room is easily accessible. Where practicable, water- 
taps should be placed on every floor, both for convenience and for 
greater safety in case of fire. It is also a result of observation that 
personal habits of cleanliness increase in a direct ratio with the ease 
of obtaining the cleansing agent. The inmates of a house where 
water is obtainable with little exertion are much more likely to be 
cleanly in habits than where the water-supply is deficient or not 
readily procured. 

VI. HOUSE=DRAINAGE. 

Provision must be made for the rapid and thorough removal of 
waste-water and excrementitious substances from the house. This is 
most easily and completely accomplished by well-constructed water- 
closets and sinks. Water-closets should, however, not be tolerated in 
any room occupied as a living- or bed- room. It would doubtless be 



206 TEXT-BOOK OF HYGIENE. 

very much more in accordance with sanitary requirements to have all 
permanent water-fixtures, water-closets, and bathing arrangements 
placed in an annex to the dwelling proper. In this way the most 
serious danger from water-closets and all arrangements having a 
connection with a cess-pool or common sewer — permeation of the 
house by sewer-air — could be avoided. 

Water-closets, however, presuppose an abundant supply of water. 
Unless this can be obtained and rendered available for flushing the 
closets, soil-pipe, and house-drain, the dry-earth or pail system should 
be adopted. Privies should not be countenanced. Experience in sev- 
eral large cities of Europe^has demonstrated 10 that the pail system 
can be adopted with advantage and satisfactorily managed even in 
large communities. 

As house-drainage may be considered the first and most import- 
ant link in a good sewerage system, a brief description will be here 
given of the details of the drainage arrangements of a dwelling- 
house. The rapid and complete removal of all fecal and urinary 
discharges, lava # tory- and bath- wastes, and kitchen-slops must be 
provided for. For these purposes are needed, first, water-closets and 
urinals, wash-basins and bath-tubs, and kitchen- or slop- sinks; 
second, a perpendicular pipe, with which the foregoing are connected, 
termed the soil-pipe; and third, a horizontal pipe, or house-drain, 
connecting with the common cess-pool or sewer. 

A. Water-closets. — There are five classes of water-closets in gen- 
eral use. They are the pan-, valve-, plunger-, hopper-, and washout- 
closets. 

Pan-closets are those found in most old houses containing water- 
closet fixtures. Just under the bowl of the closet is a shallow pan con- 
taining a little water, in which the dejections are received. On rais- 
ing the handle of the closet, the pan is tilted and the water at the 
same time is turned on, which washes out the excrement and sends it 
into or through the trap between the closet and the soil-pipe. It will 
be readily understood that the space required for the movement of 
the pan — the "container," as it is termed — is rarely thoroughly 
cleansed by the passage of water through it. Fecal matter, paper, etc., 
gradually accumulate in the corners of the container, and, as a con- 
sequence, pan-closets are always, after a brief period of use, foul. 
There are other defects in the construction of the pan-closet which 
render it untrustworthy, but the one especially pointed out — the 



See Chapter v, p. 139. 



HOUSE-DRAINAGE. 



207 



impossibility of keeping it clean — is enough to absolutely condemn 
its use, from a sanitary point of view. It is decidedly the worst form 
of closet that can be used. 

Valve-closets are merely modifications of the pan-closet. The 
bottom of the bowl is closed by a flat valve, which is held in its place 
by a weight. By moving a lever the valve is turned down, allowing 
the excreta to drop into the container. The only differences between 
the pan- and valve-closets are that in the latter a flat valve is substi- 
tuted for the pan of the former, and that this allows the container 




Fig. 17.— The "Dececo" Closet (New Form). 



to be made smaller. Otherwise there are no advantages in the valve- 
closet. Considered from a sanitary standpoint, the valve-closet is no 
worse than the pan-closet, and but very little, if any, better. 

The third variety, or plunger-closet, has several marked advan- 
tages over the two just described. The characteristic feature of the 
closets of this class is that the outlet, which is generally on one side 
of the bowl, is closed by a plunger. This bowl is always from one- 
third to one-half full of water, into which the excreta fall. On rais- 
ing the plunger, the entire contents of the bowl are rapidly swept out 
of the apparatus into the soil-pipe, the bowl thoroughly washed out 



208 



TEXT-BOOK OF HYGIENE. 




Fig. 18.— The "A. G. M." Closet. 



HOUSE-DRAINAGE. 



209 



by a sudden discharge of water, and, on closing the outlet with the 
plunger, the bowl is again partly filled with water. An overflow 
attachment prevents accumulation of too large a quantity of water in 
the bowl. This overflow, however, sometimes becomes very foul and 
objectionable. The Jennings, Demarest, and Hygeia are types of this 
class. The principal objection is that the plunger sometimes fails to 
properly close the outlet, allowing the water to drain out of the 
bowl, and thus destroying one of its principal advantages. The me- 
chanism is also somewhat complicated and likely to get out of order. 




Fig. 19.— Sectional View of "A. G. M." Closet. 



The hopper-closet consists of a deep earthenware or enameled 
iron bowl, with a water seal trap directly underneath. The excreta 
are received directly into the proximal end of the trap, and when 
the water is turned on the sides of the bowl are washed clean and 
everything in the bowl and trap swept directly into the soil-pipe. 
There is no complicated mechanism to get out of order, the trap is 
always in sight, and the entire apparatus can always be kept clean 
and inoffensive, as there are no hidden corners or angles for filth 
to lodge. This form of closet is, all things considered, one of the 
best for general use. 

14 



210 TEXT-BOOK OF HYGIENE. 

The "wash-out" closets are of various shapes, some having the 
trap in the bowl itself, others having a double water-trap. They are 
generally simple in construction, and not likely to get out of order. 
They do not present any decided advantages over the simple hopper, 
although at the present time they are more used than any other form 
of closet. Of the recent improvements in this form of closet may 
be mentioned the "A. G-. M.," 11 shown in view with intern in Fig. 18, 
and in section in Fig. 19, and the "Dececo," Fig. 17, invented by Col. 
George E. Waring. In the latter the automatic siphon principle, so 
ingeniously used by Rogers Field in the construction of the automatic 
flush-tank, is applied to the scouring of a water-closet. Practical 
experience for a number of years has demonstrated the great useful- 
ness of this closet. If the delivery of water from the flushing-cistern 
is properly regulated, at first rapid to thoroughly wash out the closet 
and connections, and then slow to re-establish the proper depth of 
seal in the trap, the closet should be thoroughly satisfactory in its 
workings. 

Water-closets should not be inclosed in wooden casings, as is al- 
most universally done. Everything connected with the closet, soil-, 
and drain- pipes, water-supply, and all joints and fixtures should be 
exposed to view so that the defects can be immediately seen and easily 
corrected. By laying the floor and back of the closet in tiles or cement, 
such an arrangement can even be made ornamental, as suggested by 
Waring, 12 who saj 7 s that a closet "made of white earthenware, and 
standing as a white vase in a floor of white tiles, the back and side 
walls being similarly tiled, there being no mechanism of any kind 
under the seat, is not only most cleanly and attractive in appearance, 
but entirely open to inspection and ventilation. The seat for this 
closet is simply a well-finished hard-wood board, resting on cleats a 
little higher than the top of the vase, and hinged so that it may be 
conveniently turned up, exposing the closet for thorough cleansing, or 
for use as a urinal or slop-hopper." 

Where the arrangement here described is adopted, extra urinals 
are unnecessary and undesirable. Where they are used they should 
be constancy and freely flushed with water, otherwise they become 
very offensive. The floor of the urinal should be either of tiling, slate, 
or ename ] ed iron. 



11 Manufactured by the Myers Sanitary Depot, New York. 

12 Sanitary Condition of New York City, Scribner's Monthly, vol. xxii, 
No. 2, June, 1881. 



HOUSE-DRAINAGE. 



211 



B. Water-supply for Closets. — The water-supply for flushing 
water-closets should not be taken directly from the common house- 
water supply, but each closet should have an independent cistern large 
enough to hold a sufficient quantity of water for a thorough flushing 
(20 to 30 litres) every time the closet is used. The objections to 
connecting the water-closet directly with the common house-supply 
are, that there is often too little head of water to properly flush the 




basin; and, secondly, if the water be drawn from a fixture in the 
lower part of the house, while the valve of a water-closet in an upper 
floor is open at the same time, the water will not flow in the latter 
(unless the supply-pipe is very large), but the foul air from the closet 
will enter the water-pipe, and may thus produce dangerous fouling 
of the drinking-water. Hence, separate cisterns for each water-closet 
should always be insisted upon. 

The arrangement of these cisterns is often difficult to compre- 
hend. Fig. 20 shows the interior arrangement of one form. The 
ball-shaped float, a, cuts off the supply when the tank is full, while 
opening the valve, b, by means of the crank, c, discharges the water. 
The rounded annex, d, contains water enough to partly fill the closet- 



212 



TEXT-BOOK OF HYGIENE. 



bowl and trap after the contents have been washed out by the rapid 
flush. 

C. Traps. — Every water-closet, urinal, wash-basin, bath-tub, and 
kit (.hen-sink should have an appropriate trap between the fixture and 
the soil-pipe. The trap should be placed as near the fixture as prac- 
ticable, as pointed out above; in the best forms of water-closet the 
bottom of the closet itself forms part of the trap. 

Traps differ in shape and mechanism. The simplest and usually 
efficient is the ordinary S-trap (Fig. 21). This trap is of uniform 
diameter throughout, and has no angles for the lodgment of filth. 
A free flush of water cleanses it perfectly, and it rarely fails to 
furnish a sufficient obstruction to the passage of sewer-air from the 
soil-pipe, unless the water has evaporated or been forced out under 
a back-pressure of air in the soil-pipe, or been siphoned out, and thus 
the seal broken. 



m 



Fig. 21.— S-Trap. 



The D-trap and bottle-trap are objectionable on account of the 
great liability of becoming fouled by filth lodging in the corners, 
while in the mechanical traps, like Bowers' ball-valve trap, Cudell's 
trap, and others of this class, there is always danger of insufficient 
seal by filth adhering to the valve, and thus preventing its exact 
closure. 

Most of the traps now furnished by the dealers in plumber's 
supplies have an opening in the highest part for attaching a vent- 
pipe. It has been found that the seal in most traps can be broken 
by siphonage, if the pressure of air on the distal side (the side 
toward the soil-pipe) of the trap is diminished, or, on the other hand, 
by increase of pressure in the soil-pipe the water in the trap may be 
forced back into the fixture, and thus sewer-air enter the room. By 
providing for a free entrance and exit of air to the trap this break- 
ing of the seal can be prevented. The ventilation of traps is, however, 
an evil, as it furnishes an additional means of evaporation, and when 



HOUSE-DRAINAGE. 



213 



the fixture is not in frequent (daily) use the seal is sooner broken. 
The elaborate extra system of ventilation of traps, so generally insisted 
upon by plumbers and sanitary engineers, is unnecessary. If the soil- 
pipe is of the proper size and height, siphonage of traps will not be 
likely to occur. The waste-pipe connecting the fixture and the soil- 
pipe should be as short as possible; in other words, all water-closets, 
urinals, baths, and lavatories should be placed as near the soil-pipe 
as practicable, in order to have no long reaches of foul waste-pipe 
under floors or in rooms. 




Fig. 22. Fig. 23. 

Fig. 22. — Sectional View of Vent, with Cap in Normal Position. 

Fig. 23. — Sectional View of Vent, with Cup Lifted out of the Mercury 
by the Inflowing Current of Air Indicated by the Arrows. 



Dr. E. S. McClellan has recently invented a trap which obviates 
many of the objections urged against all previous devices, and is 
intended to meet the defects of the S and other traps. It consists of 
a body containing a light, inverted cup, with its edges resting in an 
annular groove containing mercury, which forms an absolute seal 
against the escape of sewer-air. When a slight diminution of pressure 
occurs on the sewer side of the cup, the greater external pressure lifts 
the cup out of the mercury and permits a free inflow of air until the 
wonted equilibrium is re-established, when the cup drops back into 
the mercury by gravity, and effectually closes the trap against any 



214 



TEXT-BOOK OF HYGIENE. 



outflow. With this trap siphonage of the seal is impossible. Fig. 
22 Bhows this trap with the cup down, and Fig. 23 with the cup 
raised, allowing inflow of air. 

For an ordinary wash-bowl or bath-waste (which should always 
be trapped), the Connolly globe-trap, shown in Figs. 24 and 25, is 
an excellent fixture. It is impossible, under ordinary circumstances, 
to break the seal by siphonage. 

D. The Soil-pipe. — The vertical pipe connecting the water-closets 
and other fixtures with the house-drain is called the soil-pipe. It 





Fig. 24. — Connolly Globe-trap. 



Fig. 25. — Globe-trap Attached to Basin. 



should be of iron, securely jointed, of an equal diameter (usually 10 
centimetres) throughout, and extend from the house-drain to from 
iy 2 to 2 metres above the highest point of the house. The connec- 
tions of all the waste-pipes from water-closets, baths, etc., should be 
at an acute angle, in order that an inflow at or nearly at right angles 
may not produce an obstruction in the free passage of air up and 
down the soil-pipe. The diameter of the soil-pipe, at its free upper 
end, should not be narrowed ; in fact, according to Col. Geo. E. War- 
ing, the up draught is rendered more decided if the upper extremity 






HOUSE-DRAINAGE. 215 

of the soil-pipe is widened. 13 The internal surface of the pipe should 
be smooth, and especial care should be taken to prevent projections 
inward at the joints; otherwise, paper and other matters will adhere 
to the projections, and gradually obstruct the pipe. 

E. The House-drain. — The horizontal or slightly inclined pipe 
which connects the lower end of the soil-pipe with the sewer or cess- 
pool, the point of final discharge from the house, should be of the same 
diameter and material as the soil-pipe. The joints should be made 
with equal care, and the pipe should be exposed to view throughout 
while within the house-walls. If sunk below the floor of the cellar 
it should be laid in a covered trench, so that it may be readily in- 
spected. The junction between the vertical and horizontal pipe 
should not be at a right angle, but the angle should be rounded. The 
drain-pipe should not be trapped. This is contrary to the advice of 
sanitary authorities generally, but the author thinks it unadvisable 
to trap the drain-pipe. There should be no obstruction to the out- 
flow of sewage from the house, and a trap in the drain-pipe is of 
no avail against the passage of sewer-air from the sewer or cess- 
pool into the soil-pipe, if the pressure of air in the former is increased. 
Furthermore, if the passage of air backward and forward between the 
sewer and the external air at a sufficient height (above the roofs of 
houses, for example) is free and unobstructed, the sewers (or the cess- 
pool, as the case may be) will be better ventilated than if any obstruc- 
tion to such free circulation, in the form of a trap, be placed in the 
drain-pipe. 

Nearly all sanitary authorities direct that an opening for the 
admission of fresh air — "fresh-air inlet" — should be made in the 
drain-pipe, before its connection with the sewer or cesspool. This 
is done with the view of having a constant current of fresh air enter- 
ing near the base of the soil-pipe and passing upward through it. 
Theoretically, the current ought always to pass in this direction. 
Practically, however, the current is found, at times, to pass the other 
way, and the foul air from the soil-pipe may be discharged into the 
air near the ground, where it would be much more likely to do harm 
than when discharged high up in the air beyond the possibility of 
being breathed. 



"Am. Architect, p. 124, Sept. 15, 1883. 



216 TEXT-BOOK OF HYGIENE. 

OFFICIAL SUPERVISION OF THE SANITARY ARRANGEMENTS 
OF DWELLINGS. 

In most towns and cities the municipal authorities have pro- 
vided for an official inspection of buildings, to prevent neglect of pre- 
cautions against fire and other manifest dangers to life. It is 
only very recently, however, that the authorities of some of the larger 
cities in this country have enacted laws to prevent improper construc- 
tion of house-drainage works. Although none of these laws or or- 
dinances cover the subject completely, yet their proper enforcement 
must result in great advantage. 

Within the past few years, following the example of Edinburgh, 
volunteer associations have been organized in various cities of this 
country, with the object of securing constant expert inspection and 
supervision of the drainage arrangements of dwellings and other 
necessar}^ sanitary improvements. 

The good results accomplished by the Newport Sanitary Protec- 
tion Society, the New Orleans Auxiliary Sanitary Association, and 
other similar bodies attest the usefulness of such organizations. 

THE INTERIOR ARRANGEMENT OF THE HOUSE. 

A dwelling is neither a store-house for furniture, a museum, nor 
a picture gallery. It is a place to live in with comfort and in accord- 
ance with Irygienic rules. The interior furnishing, therefore, should 
be simple and neat. The furniture, and only so much of it as is 
needed for comfort, should be of such construction as not to gather 
dust. Upholstered furniture, with the exception of plain leather, is 
unsanitary and should not be tolerated. The floors should be polished 
and covered with rugs. The guiding principle in all cases should be 
a maximum of space and a minimum of dust. 



QUESTIONS TO CHAPTER VI. 

CONSTRUCTION OF HABITATIONS. 

Why should the principles of hygiene be observed in the construction 
of dwellings? What relation is there between badly-constructed and over- 
crowded dwellings in cities? Between overcrowded dwellings and the death- 
rate, either general or from contagious diseases? What class of persons are 
especially affected by overcrowding and unsanitary conditions of their dwell- 
ings? 

What points should be taken into consideration in building a house? 
What things are to be sought and what avoided in selecting a site? On what 
kind of soil should the house be built? How far should the ground- water be 
below the surface, even at its highest? What must be known about a soil 
to determine whether it is sanitarily suitable for building purposes? What 
is the usual judgment concerning sites on granite, trap, or metamorphic 
rocks? What if they have been disintegrated? What regarding those on the 
clay slate? Limestone and magnesian limestone? Chalk? Sandstone? Gravel? 
Sands? Clays and alluvial soils? Cultivated lands? Which of the above 
is probably the best, on general principles, for the site for a dwelling? Where 
a site is wet or the soil is impure, what must be done? What is the mini- 
mum depth at which drains for the soil-water should be laid? How else may 
the drying of the soil be promoted? How should a cellar or basement over 
an impure soil be paved? What precaution should be observed in building a 
house against a hill? 

What are some of the materials of which the walls of a house may be 
built? What are the advantages of good brick? Why should very porous 
sandstone not be used for building purposes in cold climates? What is the 
effect of paint upon house-walls? Has calcimining or white-washing the 
same effect? Has wall-paper? How soon should newly-built houses be occu- 
pied ? To what are moist walls sometimes due, and how may they be obviated ? 

What should be the minimum height of rooms in dwelling-houses? How 
much air-space should there always be in sleeping-rooms for adults and chil- 
dren? What is the standard of purity of the air that should be maintained 
constantly? What are the objections to heating by hot-air furnaces, and how 
may these objections be avoided? How may a room be ventilated without ex- 
pensive apparatus? 

What colors should be avoided in~wall-paper and paints for inside work, 
and why? What should be the proportion of window-space to floor-space, and 
what other points should be observed in the day-lighting of rooms? What 
are the forms of artificial light used for household illumination, and what are 
the dangers accompanying each ? What are some of the especial advantages 
of the incandescent electric light? From what direction should the light 

(217) 



•2 IS QUESTIONS TO CHAPTER VI. 

come for writing, reading, etc.? Why must there be increased ventilation 
whore artificial lights (except incandescent electric) are used? How much 
fresh air per hour is needed to properly dilute the impurities produced by 
burning illuminating gas? 

What points are to be observed regarding the water-supply of a dwell- 
ing? Why should it be both abundant and convenient? 

How are waste-waters and excrementitious matters most readily re- 
moved from a house? Where would it be best to have all fixtures, etc., 
of a house-drainage system located, if possible? What do water-closets, etc., 
presuppose? If this cannot be had, what system should be adopted instead? 
For what must a proper house-drainage system provide? What are the 
component parts of such a system? 

Where should water-closets never be located? What five classes of 
water-closets are there? Which of these are most objectionable, and why? 
Describe briefly the construction of a pan- and a valve- closet. In what way 
is a plunger-closet better than a pan- or valve closet? Wherein is it sani- 
tarily imperfect? Why is the hopper-closet one of the best? What two kinds 
of hopper-closet are there? What can be said of the wash-out closets? What 
is the principle of siphon closets? Why should water-closets and other fixtures 
not be inclosed in wooden casings? How may the surroundings of such closets 
and fixtures be further improved? Why should the water-supply for closets 
not be taken directly from the house-supply? How much should the flushing 
cistern hold? 

What are traps? Where should they be located? How many should 
there be in any system of house-drainage? What is the simplest form of 
trap? What are its advantages? Upon what does the value of a trap depend? 
What is to be avoided in the selection of a trap? What is meant by siphon- 
age? How can this be prevented? To what part of the trap is the vent-pipe 
to be attached? Where should the other end of the vent-pipe open? How 
else may the seal of a trap be broken? What is the principle of McClellan's 
anti-siphon trap? 

How long should the waste-pipe connecting the fixtures with the soil- 
pipes be? What is the soil-pipe? Of what dimensions should it be? Where 
should its upper extremity end? What other precautions should be observed 
in regard to the soil-pipe? 

What is the house-drain? What care must be observed in the laying of 
it? What can you say regarding a trap between the house-drain and sewer? 
If a trap is thus located, what else must there be between the trap and the 
house, and why? What can be said regarding the official supervision of sani- 
tary arrangements in dwellings? What principle should underly the furnish- 
ing of a house? 



CHAPTER VIL 

CONSTRUCTION OF HOSPITALS. 

SITE. 

If the choice of a site for the habitation? of healthy persons is a 
matter of vital importance, as was pointed out in the last chapter, 
it needs no argument to impress upon the reader the actual necessity 
of choosing a site with wholesome surroundings for a habitation for 
the sick. In selecting a site for a hospital, therefore, it is of prime 
importance to avoid a location where unsanitary influences prevail. 

While a hospital should always be easily accessible, it is not 
desirable that it should be in a noisy or crowded part of a city. Where 
a hospital is primarily designed for the reception of accident or 
"emergency" cases, it is, of course, necessary to have it near to where 
accidents are likely to occur. In a city this will probably be in the 
most crowded and noisy part. 

The direction of the prevailing winds from the city should be 
avoided in selecting a site for a hospital. 

Free admission of sunlight and air must be secured to all parts 
of the hospital. An elevated location is therefore desirable, although 
exposure to violent winds must, if possible, be avoided. 

The soil upon which a hospital is built should be c'ean, easily 
drained, with a deep ground-water level, not liable to sudden oscil- 
lations. The neighborhood of a marshy or known malarious region 
should be avoided. 

THE BUILDINGS. 

The building area must be large enough to permit the construc- 
tion of buildings in accordance with the modern recognized principles 
of hospital construction. Overcrowding is not permissible, either of 
the grounc 1 ; by buildings or of the buildings by patients. 

Having determined the number of patients for whom provision is 
to be made and the character of the diseases to be treated, an estimate 
must be made of the area necessary for a hospital. Taking into ac- 
count all the buildings needed, the area required will be — for two 
or more storied buildings — not less than 30 square metres per bed. 

(219) 



220 TEXT-BOOK OF HYGIENE. 

If one-story buildings are to be erected more space will be required, 
and if infectious diseases are to be treated in the hospital the above 
space-allowance must be doubled or even trebled. In the Johns 
Hopkins Hospital, in Baltimore, the area occupied by the buildings 
is 56,000 square metres, and provision is to be made for 300 patients. 
This, covering, of course, the area occupied by the administration 
building, nurses' home, kitchen, dispensary, operating and autopsy 
theatre, laundry, etc., gives an area of 187 square metres per bed. 
The actual allowance of floor space per bed is liy 2 square metres; 
for patients with infectious diseases the space-allowance is nearly 
treble, being 29 square metres. 

Within recent years the principles of hospital construction have 
undergone considerable modification. While formerly a large hospital 
consisted usually of one large, two or more storied building, in which 
all the various departments were comprised under one roof , the aim has 
recently been to scatter the wards as much as practicable, consistent 
with reasonable ease of supervision and administration. Under the 
former plan, with large wards connected by common corridors and 
stairways, ease of administration was primarily secured; in the lat- 
ter, the most important object of a hospital, "a place for the sick to 
get well in/' is more nearly attained. While many hospitals are still 
being constructed on the old plan, of a single block of several stories 
in height, nearly all sanitary authorities are agreed that the plan of. 
separate pavilions of one or, at most, two stories, in which the build- 
ings are entirely disconnected, or connected only by means of an open 
corridor for convenience of administration, is best for the patients, 
and, leaving out of account the cost of the ground, is also the most 
economical. 

The recent development of the pavilion system of hospitals may 
be attributed largely to the success obtained in treating the sick and 
wounded in the simple barrack hospitals during the late war between 
the States. The army barrack hospital is the original type of the 
pavilion hospital of the present day. 

Each pavilion consists of one or two wards, containing from ten 
to thirty beds altogether. In each pavilion or ward is also a bath- 
and wash- room, water-closet, dining-room, scullery, attendants' room, 
and sometimes a day-room for patients able to be out of bed. 

The two-story pavilion is built on the same plan, and is generally 
adopted in cities, or where economy of space is desirable for financial 
reasons, and where no infectious diseases are treated. Where prac- 
ticable, one-story pavilions should always be adopted, as they are 



HOSPITAL BUILDINGS. 



221 



more easily heated, ventilated, and served than two-storied buildings. 
When a number of pavilions or wards are connected by a cor- 
ridor with each other, and with a central or administration building 



WOLFE ST. 




BROAJ DVJ^AY" 



] [ 



Fig. 26. — Plan of Johns Hopkins Hospital. A, Administration 
Building. B, Female Pay-ward. C, Male Pay-ward. D, Male Surgical 
Ward. E, Female Surgical Ward. F, Male Medical Ward. G, Female 
Medical Ward. H, Gynecological Ward. /, Isolating Ward. K, 
Kitchen. L, Laundry. N, Nurses' Home. 0, Dispensary. R, Patho- 
logical Building. 8, Stable. U, Amphitheatre. X, Apothecary's 
Building. Y, Bath-house. 



and other service buildings, the 'aggregation constitutes a modern 
pavilion block-hospital. The Johns Hopkins Hospital, already refer- 
red to, is a model of this class, and its plans should be studied in detail 
by all who are more particularly interested in hospital construction. 



222 TEXT-BOOK OF HYGIENE. 

The general wards are in one- and two- story buildings, connected 
by a corridor with each other and with the administration and ser- 
vice buildings. In addition to two buildings containing private 
rooms and small wards for patients able to pay for the extra accom- 
modations, there is a line of pavilions running from east to west. The 
corridor cuts all the pavilions near the north ends of the buildings, 
separating the ward almost entirely from the service part of the 
building. This arrangement leaves the south, east, and west fronts 
of the wards entirely exposed to the sun's rays — a very important 
advantage. The kitchen and laundry are at opposite angles of the 
grounds, while the autopsy building is placed in the extreme north- 
east corner of the grounds, as far from all the wards as practicable. 
The free space between the separate pavilions should be at least 
twice the height of the building. In the Johns Hopkins Hospital, 
the space is 18 metres between the one-story common wards, which 
are 11 metres in height from the surface of the ground to the ridge 
of the roof. 

VENTILATION AND HEATING. 

The cubic space (initial air-space) per bed in the wards should 
not be less than 1500 to 2000 cubic feet (42 to 56 cubic metres), and 
for surgical or lying-in cases and contagious diseases, 70 cubic metres 
should be allowed. The ventilating arrangements should secure an 
entire change of the air two to three times an hour. 

In most sections of the United States, natural ventilation can 
be relied on to keep the air in hospital wards pure (assuming, of 
course, the proper construction of the buildings). The windows, 
doors, and walls are important factors in securing this ventilation. 
Hence, especial care is to be paid to their construction and arrange- 
ment. 

Many German, French, and English authorities on hospital 
building urge the importance of making the walls impervious by 
cement, glass, or paint. The peculiar odor known as "hospital odor," 
it is asserted, cannot be prevented in any hospital in which the floors, 
walls, and ceilings are not absolutely impervious. The American 
practice is generally in favor of walls which permit transpiration of 
air. In the experience of the authpr the imperviousness of the walls 
is not necessary to secure freedom from hospital odor. It remains 
a question for serious consideration whether the diminution of natural 
ventilation would not counterbalance any good resulting from non- 
absorptive walls. 



VENTILATION AND HEATING. 223 

The interior of the walls should be perfectly smooth and plain; 
no projections, cornices, or offsets of any kind are permissible. The 
desirability of this restriction was clearly expressed over a hundred 
years ago by John Howard: "From a regard to the health of the 
patients, I wish to see plain, white walls in hospitals, and no article 
of ornamental furniture introduced." 1 

Windows should run quite to the ceiling, and should not be 
arched, but finished square at the top. There should be one window 
for every two beds. The window-sash should be double to retain heat, 
and the lights heavy, clear glass. Ventilation can be promoted by 
raising the outer sash from below and lowering the inner one from 
above. The insertion of a Sherringham ventilator at the top of the 
inner sash will aid in giving the incoming air-current an upward 
direction. 

Heating is best accomplished by introducing hot air from without, 
or by stoves or fire-places in the centre of the wards. Where hot air 
is introduced from without, it should be heated by passing it over 
steam or hot-water coils, and not by passing it through a furnace, 
which may produce super-heating and excessive dryness of the air. 

In a series of experiments by Dr. Edward Cowles at the Boston 
City Hospital, 2 the air was heated to 32° C. by passing it over steam- 
coils. It was admitted to the wards by numerous inlets 30 centimetres 
square. The best velocity for ventilating and warming purposes was 
found to be 54 metres per minute. Exit openings were in the ceil- 
ing, and it was found best to make them large, as by this means the 
rapidity of exit currents is reduced. 

Where the warming of the ward must be accomplished by stoves 
or fire-places in the ward, the best plan, for square and octagon wards, 
is to have a large central chimney with arrangements on the four 
sides for fire-places or stoves. This chimney can also be used as a 
very efficient ventilating shaft throughout the year by a device put 
in practice by Mr. John E. Neirnsee, architect of the Johns Hopkins 
Hospital. 3 In oblong wards, two or more large stoves, placed at equal 
distances along the centre of the wards, will heat the wards effectually. 

Floors should be made of tiles, slate, or oak or yellow-pine 
lumber. If wood is used, it should be well seasoned, perfectly smooth. 



x An Account of the Principal Lazarettos of Europe, etc., p. 57. London, 
1791. 

2 Report of the Massachusetts State Board of Health for 1879. pp. 231- 
248. 

3 Hospital Construction and Organization: Plans for Johns Hopkins 
Hospital, p. 335 et seq. New York, 1875. 



224 TEXT-BOOK OF HYGIENE. 

and all joints accurately made. The floor should be kept constantly 
waxed to render it impervious to fluids. 

The space between the floor and ceiling below should be filled 
with some fire-proof non-conducting material, such as cement or hol- 
low bricks, in order to isolate each floor or ward, as much as possible 
from others, both to prevent transmission of noise and extension of 
lire. 

All corners and angles on the inside of the building should be 
rounded to facilitate the removal of dust. 

In c'eaning up, care should be taken not to stir up the layers 
of dust too much by active sweeping and dusting. The floors, fur- 
niture, door- and window- casings should be wiped off with damp 
cloths. Soiled bedding, clothing, dressings, and bandages must be 
promptly removed from the ward. Mattresses and other bed-clothing 
should not be shaken in the ward. 4 

Water-closets or (where the dry method of removal of excreta is 
in use) earth- or pail- closets should be placed where they can be 
easily reached by the patients, but the apartment in which they are 
placed must not open directly into the ward. The entrance to this 
apartment should be from the corridor or, better still, from the open 
air. The ventilation of water-closets should be independent of and 
entirely distinct from that of the ward or other part of the hospital 
building. 

It is, of course, unnecessary to more than call attention to the 
vital importance of the prompt removal of all excreta, both solid and 
liquid, from the ward or hospital building. To attempt disinfection 
of excreta and allow them to remain in the ward after being voided 
is a pernicious practice, which should under no circumstances be per- 
mitted. All utensils for the reception of excreta, bed-pans, etc., 
should be immediately emptied and thoroughly cleansed. 

Urinals are not advisable ; the simple hopper-closet with hinged, 
hard-wood seat, as described in Chapter VI, is sufficient. 

A bath-room and lavatory should be attached to every ward. It 
should be placed in the service building, and be easily accessible to 
the patients. There should also be portable bath-tubs in order that 
baths may be given in the wards when necessary. 

Every large general hospital should also have a special apart- 
ment or building where baths of various kinds, such as medicated, 
vapor, Turkish, and Eussian baths, could be given. In lying-in hos- 



4 A. Wernich : Ueber Verdorbene Luft in Krankenrseumen. Volkmann's 
Samml. Klin. Vortr., No. 179, p. 24. 



VENTILATION AND HEATING. 225 

pitals, special arrangements for giving vaginal and uterine douches 
must also be furnished. 

A daily water-supply of at least 450 litres per bed should be pro- 
vided. The water should be easily accessible from the wards and 
various parts of the service building. 

All water-closets, soil- and waste-pipes must be properly trapped ; 
all joints must be properly made and all sewer connections made on 
the most improved plans. All work of this sort should be properly 
tested before being accepted, and frequently inspected afterward. 

No sewer or house-drain should be laid under a ward. 

A disinfecting chest for disinfecting soiled clothing, bedding, 
dressings, etc., should be placed in the basement of the ward, and 
connected with the latter by an iron chute, closing perfectly by an 
iron top. The best and most convenient disinfectant is steam. This 
is also the best means to destroy vermin in clothing and bedding. 

It is questionable whether a nurse's room should be attached to a 
hospital ward. The nurse's place, when on duty, is in the ward itself, 
not in a room separate from it. Where there is a nurse's room, it 
should not be furnished with sleeping arrangements, for this is a 
strong temptation to neglect of duty on the part of the nurse. A 
nurse not on duty should not be permitted to remain about the ward. 

A ward-kitchen should be in the service building, where articles 
of food can be kept hot or cold when necessary, and where special 
dressings, cataplasms, hot water, etc., can be prepared. A small gas- 
stove only should be allowed in the ward-kitchen, as the regular meals 
of the patients are prepared in the central kitchen, which should 
be totally detached from the hospital. The ward-kitchen can be 
easily utilized as a nurse's room, and in a small hospital can also 
be used as a store-room for the patients' body- and bed- linen and 
clothing. 

The dining-room for patients able to be out of bed should be 
in the service building. A room with a good light and well ventilated 
and heated should be selected for this purpose. In the intervals 
between meals this room could be used as a day-room for such patients 
as should be out of bed, but who are not able to be in the open air. 

A dead-house, containing a dead-room, autopsy-room, and a room 
fitted up for rough microscopic and possibly photographic work, is 
a necessity to every well-appointed general hospital. The dead-house 
should be entirely separate from the ward buildings. 

The kitchen should be separate from the other buildings, and 
in large hospitals should also be the central station for the heating 

15 



226 TEXTBOOK OF HYGIENE. 

arrangements, if hot water or steam is to be used. The laundry may 
be connected with it. The kitchen should be connected with the 
wards by means of a covered corridor to avoid exposure in carrying 
the food to the wards. 

The administration building should contain office-rooms for the 
superintendent and resident physician, pharmacj', library, reception- 
rooms for visitors, living-rooms for one or more assistants, and dwell- 
ings for the superintendent and resident physician. 

THE ADMINISTRATION AND MANAGEMENT OF A GENERAL 

HOSPITAL. 

The general management of a hospital should be under the direc- 
tion of a superintendent, who, besides being a medical man, should be 
especially qualified by study and experience for the work. The super- 
intendent of a large hospital should not be expected to perform any 
of the routine professional work in the wards, but he should be re- 
sponsible for the service, both professional and lay, in the hospital. 
He should be the financial officer, and in all other things concerning 
the hospital his judgment should decide. He should have sufficient 
assistance to permit all necessary duties to be promptly performed. 
For this purpose he should have a secretary, or clerk, who should not 
be a medical man; otherwise the attention of the latter might, be 
withdrawn from his clerical duties to the more interesting profes- 
sional work in the hospital. The plan advocated by some authorities, 
to have two superintendents for large hospitals — one of whom shall 
be a medical man and direct only the professional work of the hos- 
pital, while the other shall have charge of the administrative func- 
tions — does not commend itself to the author. It involves a division 
of responsibility which will, in nearly all cases, eventually lead to 
differences of opinion likely to prove unfavorable to the best interests 
of the hospital. 

It is customary in this country to appoint as resident physicians 
and surgeons in hospitals, recent graduates, whose functions are usu- 
ally limited to carrying out the directions of the visiting physicians 
and surgeons, and sometimes to act on their own responsibility in 
emergencies. This system has some advantages for the physicians, but 
is usually detrimental to the best interests of the patients. The 
resident medical officer in a large hospital should always be a thor- 
oughly qualified, experienced physician, capable of deciding promptly 
when the occasion arises, and he should be responsible to the super- 



ADMINISTRATION AND MANAGEMENT OF HOSPITAL. 227 

intendent for the proper performance of his professional duties. 
Necessarily, a physician with the qualifications indicated, would de- 
mand a very much larger salary than is usually paid resident physi- 
cians, but it should be understood that no hospital in which the good 
of the patient is the first consideration can be conducted on a cheap 
basis. 

Visiting physicians and surgeons and all resident medical officers 
should be chosen with reference to their general and special quali- 
fications for the duties expected of them. It would seem to be a good 
plan to make the selections for subordinate positions, at least, by com- 
petitive examination. 

The sick in a hospital should be properly classified. Male and 
female patients should, of course, be treated in separate wards. A 
primary classification into medical, surgical, and obstetrical cases or 
wards is also indicated. Infectious diseases, such as typhoid fever, 
erysipelas, cholera, yellow fever, croupous pneumonia, etc., should not 
be treated in the same wards with rheumatism, Bright's disease, car- 
diac and nervous disorders, or simple digestive derangements. It is 
questionable, however, whether it is advisable to make a very elaborate 
classification of the various diseases except in very large hospitals. 

An accurate record, made at the time of observation, and not 
written from memory afterward, should be kept of the history and 
progress of every case. The record should show not merely the symp- 
toms and diagnosis, but the medical and hygienic treatment. In most 
hospitals where such records are kept the entries are made either in 
a simple memorandum-book or in a more or less complicated case- 
record. A simple form of case-record has been devised by Surgeon- 
General Walter Wyman, of United States Marine-Hospital Service, 
which seems to possess advantages that render its general adoption 
desirable. 

In hospitals where cases of surgical diseases and injuries are re- 
ceived, a special apartment should be fitted up as an operating-room. 
Operations should not be performed in a ward in the presence of 
other patients. 



QUESTIONS TO CHAPTER VII. 

CONSTRUCTION OF HOSPITALS. 

What would govern you in selecting a site for a hospital? What will 
go to determine the building area? In calculating the area required for 
buildings, what relation has it to the number of beds in the hospital? In 
the wards, what should be the actual minimum floor-space for each bed for 
non-infectious and for infectious diseases? What is the difference in the 
principles of modern hospital construction and of those formerly in vogue? 
What are some of the advantages of the modern plan? What was the pro- 
totype of the present system? How many wards should each pavilion contain 
at the most? How many beds in each ward? What conveniences should there 
be in each ward or pavilion? What is meant by a pavilion block-hospital? 
What space should there be between the separate pavilions? 

What cubic space per bed should there be in the ordinary wards? What 
cases need more, and how much? How often should the air be entirely 
changed in the wards? Should the walls be pervious or impervious to the 
passage of air? How should the walls be finished? How many windows 
should there be in each ward? How high should they be? 

What is the best way to heat a hospital ward? How should hot air 
be warmed? If a ward is to be warmed by fire-places or stoves, how should 
they be arranged? 

Of what materials should the floors be made? How should they be 
treated? What should there be between ceilings and the floors above? Why? 
How should the corners and angles of floors and ceilings be finished? 

How should the wards be cleaned? What should be done with soiled 
bedding, etc.? 

Where should the water-closets, etc., be located? How should they be 
ventilated ? 

How much water should be furnished per bed? Why should no sewer 
or house-drain be laid under a ward? Where should the nurses' rooms be? 
Where the ward kitchen and dining-room? What is the administration 
building for, and what should it contain? W 7 hat officers are necessary for 
the management of a hospital? What are their duties? How should the 
resident physicians be qualified and selected? How should the sick be classi- 
fied, and what wards should there be in a general hospital? Mention some 
of the details that should be noted in the case records. 



(228) 






CHAPTER VIII. 

SCHOOL HYGIENE. 

During the period of childhood and youth the organism yields 
readily to impressions and forces, both external and internal, and it is 
therefore important that the child be safeguarded during this forma- 
tive period, and surrounded with those influences which make for good. 
Considering the number of years spent in acquiring an education and 
the length of time each day devoted to study, most of which is spent in 
the school-room, it will be readily understood why a special chapter 
should be devoted to this particular theme. School hygiene includes 
the consideration of the sanitary principles underlying the construction 
of school-houses and school-furniture, ventilation and heating; the 
proper amount of time to be devoted to study at different ages; the 
special diseases of school-children, their causes, and means for their 
prevention. It also embraces the personal hygiene of the scholar 
and his general health and habits. 

These matters are of interest to the scholar himself, to his 
parents, the citizen in general, and especially to the physician; be- 
cause as a physician he is specially fitted by his special education 
and training to serve on school-boards and committees of education, 
and because he is so often called on to treat those maladies of child- 
hood which have been caused by unsanitary conditions in school life, 
or are largely influenced thereby. 

In the construction of school-houses the same hygienic principles 
are applicable as in dwelling-house construction. The selection of a 
site for the school-building should command the same careful con- 
sideration that is necessary in determining upon a site for a dwelling. 
It should be of sufficient elevation to insure good drainage, not only of 
the sewage and refuse collected in the building, but also of surface- 
and rain- water flowing over the soil. Proximity to marshes and 
other unsanitary surroundings should be avoided. If the soil is damp 
it should be properly drained, and all sources of insalubrity in the 
neighborhood avoided or, if possible, removed. 

Especially should there be plenty of space around the building 
to insure good external ventilation, to insure the admission of an 
abundance of light, and to provide ample play-grounds for the 

(229) 



230 TEXT-BOOK OF HYGIENE. 

children. School-buildings should not be located in close proximity 
to factories, or to trades giving off smoke, dust, or noxious odors. 

School-houses should not be over three stories high; corridors 
and stairways should be wide, straight, and well lighted. All stairs 
should be securely built, and be guarded with ample, strong railing. 
All doors should open outward to permit ready egress and reduce the 
danger of accident in panics from any cause. 

Fire-drills should be held at stated intervals under direction of 
the teachers. 

In addition to the study- or recitation- rooms, provision should 
be made for play and calisthenic-exercise rooms. Well-lighted and 
ventilated side-rooms should be provided for the reception of out- 
side clothing, umbrellas, overshoes, etc. These articles should not be 
kept in the recitation- or study- rooms. 

Floors should be made of accurately-joined flooring, and ren- 
dered impervious by oil or paraffine coating. 

All corners and angles should be rounded, to prevent the accu- 
mulation of dirt. 

Appropriate measures must be employed to prevent the permea- 
tion of the building by ground-air. 

The foundation-walls should be laid in Portland cement, and 
coated inside and out with the same, and the floors should be laid 
in at least ten inches of cement. This will insure a damp-proof 
basement as well, w T hich may be used as play-rooms during in- 
clement weather, provided they be properly heated and ventilated. 

The inside walls of school-rooms may be tinted a neutral gray, 
or light blue or green. Ceilings should be white. Walls and ceil- 
ings should not be painted, but lime-coated to permit free transpira- 
tion of air. 

Schools should be so constructed as to permit of ready heating 
and ventilation, cleaning, and keeping clean. In large schools the 
method will usually be by furnace-heated air, although a better 
method would probably be by steam- or hot-water pipes. 

What is known as the "Smead system" is a most excellent one. 
It is a combined system of heating and ventilation, consisting of a 
hot-air furnace, the fresh heated air being admitted through one set 
of registers, placed in the wall near the floor, and the foul air being 
taken out through another set of flues on the same side of the room 
and at the same level. This "used-up" air is then carried from the 
building through a system of ducts passing beneath the floors of 
the rooms, the heat, by this arrangement, being further utilized to 



SCHOOL HYGIENE. 



231 



heat the floors as it escapes. In rural districts the school-room may 
be heated by means of a stove, provided with a jacket or cylinder 
surrounding it, and several feet in height. This is made of tin or 




Fig. 27. 
Fig. 27. — a, a, Sash. 



Fig. 28. 



J), J), Window-jambs, c, c, Window-sill. This 
cut represents the view from within the Bury Ventilator, in operation. 
It is broken away at one end to show the sash raised above the outer 
holes to admit the air. 

Fig. 28. — a, a, Sash. This cut represents the view from without 
the Bury Ventilator, in operation. The sash is broken away to show 
the ventilator behind, with the fresh air passing in. 



zinc. In the floor, beneath the stove, ho^s are bored to admit fresh 
air, which, warmed in passing over the stove, is deflected upward, 
and diffused, by means of the jacket. 



232 TEXT-BOOK OF HYGIENE. 

The ventilation of school-rooms must be carried out on the 
principles indicated in Chapter I. With careful and intelligent 
teachers, natural ventilation will give better satisfaction than a com- 
plicated artificial system. Where windows and doors must be largely 
depended upon for ventilation, the Bury window ventilator, here 
illustrated, will give satisfactory results unless the school-room is 
overcrowded. 

Opening the doors and windows when the pupils are out of doors 
— flushing the rooms with fresh air — is not a method to be com- 
mended. The temperature of the room is so lowered, that when the 
children, overheated from play, return to it, they may become chilled, 
and "colds" be produced. 

A model study-room, according to modern views, should be 
about 9 to 10 metres long, not over 7 metres wide, and 4 to 4 1 / 2 
metres high. Such a room could be easily lighted by windows on one 
side only, and readily heated and ventilated. It wouM also enable 
the teacher to exercise a close supervision over the pupils. In a 
room of this size forty pupils would be a proper number, although 
fifty could be accommodated. The initial air-space for each pupil 
would be 5.60 cubic metres if there were fifty pupils in the room, 
and 7 cubic metres if there were only forty. This would be slightly 
reduced by allowance for the teacher. 

It is believed that study-rooms should face toward the north. 
The light entering from the north side of a building would be 
equable during a whole day. While a larger window surface would 
be necessary than with an easterly or southerly exposure, it is held 
that the light, being devoid of all glare, would be more effective. 
When the light is admitted on the east, south, or west sides of the 
building, the direct entrance of the sun's rays must be prevented 
by curtains, by means of which the amount and proper distribution of 
the light is regulated with difficulty. 

The windows of the school-room should reach from about the 
height of the pupil's shoulder (when seated) to the ceiling. Arches 
or overhanging cornices over the windows should be avoided, as they 
cut off much light. For the same reason the near proximity of other 
high buildings and of trees should be avoided in selecting a site for a 
schoolhouse. The window area should be not less than one-fifth of 
the floor area, otherwise the light will be deficient. 

The light should be admitted only from the left side of the 
pupil. When admitted from the right side the shadow cast by the 
pen in writing interferes with good vision; if admitted directly in 



SCHOOL HYGIENE. 233 

front of the pupil, the glare of the light will injuriously affect the 
eyes; while, if it can enter from behind, the book or paper of the 
pupil will be so much in shadow as to compel him to lean so far to 
the front in bringing his eyes nearer to book or paper that nearsight- 
edness is very likely to be developed. Furthermore, if the light is 
admitted into the room at the backs of the pupils, the eyes of the 
teacher are liable to suffer from the constant glare. 

In a school-room of the dimensions above stated, a row of windows 
on one side, forming an area of glass of one-fifth of the floor-space, 
will thoroughly and satisfactorily illuminate the room, with the least 
unfavorable influence upon the organs of vision. It is advisable, 
therefore, to always insist upon this arrangement of lighting of 
school-rooms. Where artificial light is used in a school-room, it 
should be in the proportion of one burner to every four pupils. 
All burners should be provided with chimneys and vertical re- 
flectors. 

Electric lights, properly shaded, or toned down with ground glass 
or tinted globes, are to be preferred, as they do not require any 
additional ventilation. 

Water-closets and privies should not be placed in cellars or 
basements. This would seem to be self-evident, and yet in many city 
school-houses these places of retirement are in this unsuitable loca- 
tion. When it is considered that large schools are frequently warmed 
by hot air taken from the cellar, it furnishes an additional reason 
to avoid this location for water-closets. On the contrary, the cus- 
tom, in some country schools, of placing the privy at a considerable 
distance from the school-room and in an exposed situation is almost 
equally reprehensible, as the pupils, especially girls, are prone to 
neglect obeying the calls of nature, from which neglect many dis- 
orders arise. These "garden-houses" should be connected with the 
school-house by a covered way. 

Desks should be slightly sloping, the edge nearest the pupil being 
about 1 inch (2.5 centimetres) higher than his elbows. The front 
edge of the seat should project a little beyond the near edge of the 
desk, so that a plumb-line dropped from the latter should strike the 
seat near its front edge. If the seat is not thus brought slightly 
under the desk, the pupil is compelled to lean forward in writing, 
which position prevents proper expansion of the chest and increases 
the blood-pressure in the eyes — a condition promotive of near- 
sightedness. 

Seats should be only high enough so that the feet rest flat upon 



234 



TEXT-BOOK OF HYGIENE. 



the floor. If they are higher, a foot-board must be provided. 
Children should not be condemned to the cruelty of having their 
feet dangling "between heaven and earth" while they keep their seats. 
Seats and desks should be graded according to the sizes of the pupils — 
not their ages or standing in the class. 

An ideal seat and desk would be one made to measure for each 
pupil, but this is manifestly impracticable, inasmuch as with the 
constant growth of the child the seats would be rapidly outgrown. 




Fig. 29. — Adjustable School-desk (Front View). 

The desk shown in Fig. 29 1 is adjustable to children of differ- 
ent sizes, and seems to solve the problem which has so long puzzled the 
school sanitarian. The desks are made for a single pupil and the 
seat and desk are independently adjustable. The frame is of iron 
and the seat, back, and desk of hard-wood lumber. 

Blackboards should not be placed at a greater distance than 10 
metres from the farthest pupil. The ground of the board should be 
a dead black, without lustre. In writing exercises upon the board, 
care should be taken that the letters and figures are made sufficiently 
large, and with rather heavy strokes of the crayon, in order that 
they may be easily seen from the most distant part of the room. It 



S. A. 



Made by the Rushville School Furniture Company, Rushville, Ind., U. 



SCHOOL HYGIENE. 235 

has recently been demonstrated that a black letter on a white ground 
can be seen at a greater distance than a white letter on a black 
ground. Hence, it might prove advantageous to the eye-sight of 
school-children to substitute for the present blackboard and chalk, 
a white board and black crayon. In some European lecture-rooms 
this plan has been adopted with satisfaction. 

Young children should not be kept at the same study or in the 
same position for long at a time. The exercises should be frequently 
varied. It is especially with children in the primary grades that 
care should be taken not to overburden their minds with too many 
hours of study, or too long continuance at the same exercise. 

Children should not be placed in a regular school much, if at 
all, before the completion of their 7th year. Between the ages of 5 
and 7 they may be sent to a kindergarten. From 7 to 9 years they 
should be kept at their studies not longer than three hours daily; 
from 9 to 12 years four hours may be allotted them; and from 12 
to 16 years they may be kept at mental work five to six hours daily. 
This does not mean that pupils are to be kept continuously at their 
studies during these hours, but that they should be neither com- 
pelled nor permitted to study longer than these periods each day. 
It is believed that these figures represent the capacity for endurance 
in the majority of children, and they should be adopted in all schools 
where the largest return in mental acquirements is desired at the least 
expenditure of health. Excess of time expended in study is almost cer- 
tainly followed by physical deterioration. "A little less brain : a little 
more muscle," for our children, is a legitimate demand that we 
may make of legislators and school-boards. 

Gymnastic exercises should form part of the daily routine in 
all schools. These exercises should take place, when practicable, in the 
open air. Playing, romping, laughing, and singing should be en- 
couraged, rather than the natural tendency to boisterous play re- 
strained. It is especially desirable that female children should be 
encouraged to take part in these diversions. The desire, on the part 
of many parents, to see little girls deport themselves as young ladies, 
before the time even when they write their age in two figures, is 
very reprehensible, and deserves the most unqualified condemnation. 
Moliere's satirical remark, "II n'y a plus d'enfants," 2 seems to be 
literally true at the present day. 

The principal diseases incident to school-life are myopia, spinal 
deformities, nervous and digestive disorders, pulmonary phthisis, and 

2 There are no more children." 



236 



TEXT-BOOK OF HYGIENE. 



the communicable diseases, viz.: chicken-pox, small-pox, erysipelas, 
measles, rotheln, scarlatina, typhoid fever, and contagious ophthalmia. 
By judicious sanitary measures these can all be very much diminished 
and some entirely prevented. 

It has been shown by the examination of the eyes of school- 
children that near-sightedness increases progressively from the low- 
est to the highest classes. Children who enter school with an hered- 
itary tendency to myopia, or who are, perhaps, already near-sighted 




Fig. 30. — Myopia According to School-classes — Boys. 

to a slight degree, soon become more intensely myopic; while others, 
who may be even hypermetropic on entering school, will be found 
to have become near-sighted during school-life. In examinations of 
over 30,000 pupils of grammar and high schools in Germany, Austria, 
Russia, and Switzerland, it has been found that the average pro- 
portion of near-sightedness is a fraction over 40 per cent., varying, 
in the different classes, from 22 per cent, for the lowest to 58 per 
cent, for the highest classes. These figures represent the averages 
of all the examinations made. In some particular schools, for ex- 



SCHOOL HYGIENE. 



237 



ample in the gymnasium (high school) of Erlangen, the percent- 
age in the higher classes was 88 per cent., in the gymnasium of 
Coburg, 86 per cent., and in the gymnasium of Heidelberg the pro- 
portion of myopic students in the highest class is said to have reached 
100 per cent, in 1877. In the primary schools the percentage was 
found to be much lower. Eecent investigations in the schools of 
Stockholm, by Widmark, show that among school-children examined 
under 7 years of age there was no myopia. In the higher classes the 
myopia increases not only in degree, but in frequency. The diagrams, 
Figs. 30 and 31, show graphically the increase in degree and fre- 



Class 



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izt 



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V 



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Fig. 31. — Myopia According to School-classes — Girls. 



quency of myopia in the several school-classes. These observations 
show that the number of myopic individuals bears a constant relation 
to the intensity of use of the visual organs. The results of the obser- 
vation of different observers in different countries also uniformly point 
to the conclusion that not only does the number of near-sighted 
pupils increase as the higher classes are reached, but the degree of 
myopia increases likewise. Thus, a pupil who may have only a mod- 
erate degree of myopia on entering the school will have n^opia in a 
higher degree as he advances in his classes. Erismann found, on re- 
examining the same pupils annually, that in six years 13.14 per cent. 



238 TEXT-BOOK OF HYGIENE. 

of those examined had developed myopia from emmetropia, while in 
24.57 per cent, of near-sighted pupils the degree of myopia had in- 
creased. 3 

The principal causes of the prevalence of near-sightedness in 
schools are badly-arranged or insufficient light, bad air, over-heating 
of the school-rooms, improper construction of desks compelling 
children to lean forward while reading or writing, and badly-printed 
text-books. The use of small type, poor paper, and bad press-work 
in text-books is very reprehensible. The type technically known as 
Long Primer is the smallest that should be used in text-books. That 
badl} T -arranged light and improper seats are causes of myopia has 
been shown by Forschutz in his examinations of the pupils in the 
public schools of Coburg. He found that in the newer schools, in 
which the light and seats are better arranged, the percentage of near- 
sight decreased. The average percentage of those examined in 1874 
was 21, while in 1877 it had been reduced to 15, 4 showing the great 
improvement due to the application of correct sanitary principles in 
the construction of school-houses. 

Defective hearing has recently been shown to be especially fre- 
quent among school-children. A Berlin aurist found 1392 children 
out of 5902 (23.6 per cent.) suffering from ear disease of some kind. 
Dr. Samuel Sexton, of New York, and the late Dr. Chas. F. Percivall, 
director of music in the public schools of Baltimore, have arrived 
at similar results after examination of a large number of school- 
children. 

Spinal curvature is present in a large proportion of the children 
attending schools. Statistics are not very full upon this subject, but 
one author, Guillaume, states that he found lateral curvature of the 
spine in 218 out of 731 school-children — a proportion of 29.5 per 
cent. This, of course, includes the slighter degree of curvature, 
which cannot be properly termed a disease. Among 30,000 Danish 
school-children 13 per cent, had some variety or degree of spinal 
deformity. M. Eulenburg, 5 found that among 1000 persons with 
lateral curvature of the spine, the disease began in 887 between the 
ages of 6 and 14; that is to say, during the years of school-life. 
Girls are affected more than ten times as often as boys, the proportion 
being 93.43 per cent, in the former and only 6.57 per cent, in the 
latter. 



3 Erismann. Die Hygiene der Schule, in von Pettenkofer und Ziemssen's 
Handbueh der Hygiene, 'il Th., 2 Abth., p. 30. 

4 Quoted by Cohn in Realencyclopsedie d. ges. Heilk., Bd. XII, p. 263. 
6 Realencyclopsedie d. ges. Heilk., Bd. XI, p. 564. 



SCHOOL HYGIENE. 



239 



The especial causes of spinal curvature occurring during school- 
life are improperly-constructed seats and desks and an improper 
position of the body. Many pupils habitually assume a "twisted" 
position, which is very liable to produce spinal distortion in children 
of weak muscular development. The manner in which a desk that is 
too high for the pupil may produce spinal distortion is very well 
shown in Fig. 32. An improper position is more likely to be un- 
consciously assumed by girls than by boys. The clothing is respon- 
sible for this, for when the girl files into her place behind the desk, 
her clothing, hanging loosely about her, is swept back and forms a 




Fig. 32. — Showing Influence of a High Desk in Causing Spinal 
Curvature. 



pad, upon which she sits with one buttock. Another cause of this is 
a habit many girls have of sitting on one foot. The greater eleva- 
tion of her seat on that side throws the spinal column out of the 
vertical line, which is compensated by a partial twisting of the trunk. 
The attention of teachers should be directed to this faulty habit, 
which can be easily corrected, and its consequences averted by timely 
interference. 

Nervous disorders are comparatively frequent among school- 
children. Headaches are often due to insufficient ventilation, im- 
proper food, bad digestion, and excessive mental strain. Defective 
light may also be the cause of headaches by causing ocular fatigue. 



240 TEXT-BOOK OF HYGIENE. 

Disordered menstruation in girls is a frequent cause which is 
not to be overlooked. Hysterical and imitative affections are not in- 
frequent, and sometimes pass through entire schools, including even 
the teachers. Girls are, of course, more subject to this class of dis- 
orders than boys, but the latter are not entirely exempt. 

Chorea is one of the nervous disorders which should debar the 
child who has it from school, not only on the child's own account, 
but also because the trouble may be transmitted to other children 
through association and imitation. 

Derangements of the digestive organs are exceedingly frequent 
among school-children. They can generally be traced to the use of 
improper food. The eating of cold lunches should be discouraged as 
much as possible. 

Nuts, candies, pies, fruit-cakes, bananas, and above all, pickles 
are most fruitful sources of digestive derangements of children. The 
absence of proper accommodations to enable children — especially 
girls — to answer the demands of nature are frequent sources of diges- 
tive and nervous disorders. 

The seeds of pulmonary consumption are frequently implanted 
during school-life. A neglected cough; bad ventilation, under which 
term may be comprised overheating and cold draughts, as well as 
polluted air; improper position of the body, excessive mental work, 
underfeeding, and the failure to exclude children who are the sub- 
jects of tuberculosis, may, any of them, be the starting-point of this 
fatal disease. 

Especial care should be taken to prevent the introduction or 
dissemination of communicable diseases through schools. The im- 
portance of this duty should be at all times impressed upon school- 
boards and teachers. In the first place, no child should be admitted 
within the door of the school-room unless it first presents undoubted 
evidence of protection against small-pox, either by having passed 
through a previous attack or by a proper vaccination. In case of an 
actual or threatened epidemic of small-pox the entire school, including 
teachers, should be vaccinated. 

Children should not be admitted to school coming from a house 
where there is at the time, or has recently been, a case of communi- 
cable disease, such as small-pox, diphtheria, scarlet fever, or measles. 
They should be excluded in each case for a period of time equivalent 
to the incubation of the given disease. It goes without saying that 
no child having itself been sick with a communicable disease should be 
admitted to school until entirely restored to health. 



SCHOOL HYGIENE. 



241 



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242 



TEXT-BOOK OF HYGIENE. 
Table XXXI. 

Whi.'elegge's Table. 



Diseases 


© K a 

.2 ^ « 

is 2 
Is* 3 


Earliest Date of Return to School After 
an Attack. 


Small-pox 


18 days 
18 days 

14 days 
12 days 
16 days 
16 days 

21 days 

24 days 


When all scabs have fallen off. 


Chicken-pox 


W T hen all scabs have fallen off. 


Scarlet fever 


^ Six weeks, and then only if no des- 

l quamation or sore throat. 

S Three weeks, if convalescence is coin- 

l plete, and no bacilli remain. 

S Three weeks, if all desquamation and 

( cough have ceased. 

( Two to three weeks, according to the 

( nature of the case. 

f Six weeks from the commencement of 

the whooping, if the characteristic 
■{ spasmodic cough and whooping have 

ceased. Earlier, if all cough be 
I gone. 

( Four weeks, if all swelling has sub- 
( sided. 


Diphtheria 


Measles 


German Measles 


Whooping Cough 


Mumps 





School quarantine should be established for the following dis- 
eases: In small-pox and chicken-pox, until every scab has fallen. 
In whooping cough, until the spasmodic cough and characteristic 
whoop have ceased. In diphtheria, for at least three weeks, but in 
every case until a bacteriological examination of nose and throat proves 
that none of the specific organisms are present, and there must also 
be no discharge from the nose, throat, ears, or eyes, and no album- 
inuria. In scarlet fever, for six weeks from the time the rash appears, 
provided also that desquamation and cough have ceased. In measles, 
until desquamation is complete. In contagious ophthalmia, until 
complete recovery of the patient. In every case there must be thorough 
and efficient disinfection of the home, clothing and person of the child 
before he returns to school. 

When a case of contagious disease has accidentally obtained en- 
trance to the school, the pupils should be dismissed for the day, and 
the room thoroughly disinfected by means of formaldehyde. 

Teachers are not infrequently guilty of the grave imprudence of 
sending pupils from the school to the house of an absent child to 
inquire the reason of the latter's non-appearance at school. It fre- 



SCHOOL HYGIENE. 243 

quently happens that the absent child is sick, and the messenger is 
invited to the sick-room to see his or her class-mate. There can be 
no room for doubt that scarlet fever, diphtheria, and measles have 
often been introduced into schools in consequence of such thoughtless- 
ness on the part of teachers. 

All schools should be inspected daily by a physician appointed for 
the purpose. 

In order to promote the proper hygienic management of schools, 
all teachers should be required to submit to an examination in the 
principles and practice of hygiene, at least so far as school hygiene 
especially is concerned. This is a demand that school-boards could 
reasonably insist upon, and there can be no question that the improve- 
ment in the health of the pupils would amply justify it. 

In all boarding-schools there should be an infirmary, properly 
equipped for isolating cases of communicable disease. This infirmary 
should preferably be located in 'the upper story of the building, or in 
an isolated wing. 

A phase of school life which is seldom discussed and generally 
tabooed is the sexual development of the pupils. There is no doubt 
that vicious sexual habits are often acquired at schools, more espe- 
cially boarding schools and dormitories. It should be incumbent 
upon teachers to keep a watchful eye on this phase of school life with 
a view of detecting vicious practices. The course on school physiology 
should include the study of sexual development in plants and the 
lower animals; while among the older pupils the results of sexual 
abuses and venereal diseases may be properly discussed. 






QUESTIONS TO CHAPTER VIII. 

SCHOOLS. 

What does the hygiene of schools comprise? What principles are ap- 
plicable in the construction of school-houses? What is to be sought, and 
what avoided, in the selection of a site? 

What should be the limit of height for school-houses? What rooms are 
needed besides those for study or recitation? What precautions must be 
observed regarding stairs, railings, and doorways? How may the ground-air 
be kept out of the building? What kinds of floors should the various rooms 
have? 

What will be probably the best means of heating a school-house? What 
is the usual method in large schools? Which will usually give the best ven- 
tilation, natural or artificial? When and how may school-rooms be ventilated 
to advantage? 

How large should an ordinary school-room be? What are the advan- 
tages of a room of this size? How many pupils would this accommodate, and 
about how much air-space would each have? Is this sufficient? 

On which side of the room should the windows be, if possible? How 
should the seats and desks be arranged in relation to the windows? What 
should be the relation of window-area to floor-area ? How high should the 
windows be above the floor, and how near to the ceiling should they reach? 
What are the objections to windows on two sides of the room ? Will windows 
of the above dimensions properly illuminate the room? How much artificial 
light will be needed for proper illumination? What should be the color of 
walls and ceilings? 

Where should the water-closets, etc., of a school be located? What 
supervision of these must be exercised? 

How high should school-seats be? What should be the relation of seat 
to desk, and how high should the latter be? Why should the front edge of 
the seat be brought under the desk? 

How far should the black-boards be from the pupils? On which side 
of the room? How should the surface be finished? 

When should a child begin to go to school? What is the maximum 
time advisable for daily study at the respective ages? What should be the 
length of lessons and recitations for each age? What is an almost certain 
result of too long study-hours? What should form part of the daily school- 

(244) 



QUESTIONS TO CHAPTER VIII. 245 

routine? Should this be taken from the recess period, or should it be part 
of the school-work? 

What are some of the diseases incident to school-life? Can these be 
prevented? Are they altogether due to school-life? How does the proportion 
of cases of near-sightedness vary in school-children? Is the increase one of 
degree or of frequency? What are the causes of this excess of myopia? If 
these causes £.re avoided or corrected, will the prevalence of myopia decrease? 

What other sense is defective among school-children? What physical 
deformity is very prevalent? What are the special causes of this deformity? 
Why is it apt to be more common among girls ? At what age is the deformity 
most apt to begin? 

What nervous disorders are frequent among school-children? What are 
some of the causes of chronic headache? What pupils are most subject to 
hysterical affections? What are some causes of nervous disorders? Of diges- 
tive disturbances? 

How may consumption or other forms of tuberculosis be due to the 
school-life? What precautions should be observed in regard to the prevention 
of the spread of infectious diseases among school-children? What diseases are 
to be especially guarded against, and how shall this be done? W T hat should 
be the shortest limit of quarantine against a pupil that has had any one of 
these diseases? If a case of infectious disease gains entrance to the school, 
what is to be done? Why should teachers be required to pass an examination 
on the principles of hygiene? 



CHAPTER IX. 

INDUSTRIAL HYGIENE. 

One of the most interesting chapters in the study of hygiene 
is that which treats of the relations of occupations to health and 
life. While it is unquestionable that certain occupations are intrins- 
ically dangerous to health, there can be no doubt that in many in- 
stances incidental conditions not necessarily connected with the occu- 
pation are factors in the production of disease. Such factors are bad 
ventilation and other insanitary surroundings, as well as in many 
cases want of sufficient or proper food.. 

Occupations induce disease by compelling the workmen to inhale 
irritating, poisonous, or offensive gases, vapors, or dust; or by caus- 
ing the absorption through the skin or mucous membranes of irritat- 
ing or poisonous substances. Changes of temperature, as exposure to 
great heat or cold, produce diseases which are, in some instances, char- 
acteristic. In another class of cases the excessive use of certain organs, 
as the nervous system, the eyes, the vocal organs, or various groups of 
muscles, produce characteristic morbid effects. Again, a constrained 
attitude while at work, a sedentary life, or occupations involving ex- 
posure to mechanical violence are recognized sources of disease and 
death. 

The table on page 247 gives the mortality and average age at 
death of all decedents over 20 years of age whose occupation was 
specified, in the State of Massachusetts, for thirty-one years and eight 
months. The total number of decedents was 144,954; the average 
age at death, 50.90 years. Subdivided into classes and individual 
occupations, the results are given in Table XXXII. 

The latter table, cannot be absolutely relied upon for several 
reasons, the principal of which is that the table is incomplete. Many 
of the occupations are merely temporary, and persons are constantly 
shifting from the pursuit of one calling to another. Judges and 
lawyers, for example, should be included under one heading, while 
the class "students" should be excluded altogether. The table shows, 
however, very clearly, the relations of certain occupations to longevity. 
It is seen, for example, that agriculturists have the greatest expecta- 
tion of life. Next to these come mechanics engaged out-of-doors. 
Professional men come next, and of these clergymen and members of 
(246) 



INDUSTRIAL HYGIENE. 



247 



Table XXXII. 

Occupations of Persons whose Occupations were specified, and whose Deaths were 
registered in Massachusetts during a period of thirty-one years and eight 
months, ending with December 31, 1874. 1 



Occupations. 



Class I. Cultivators of 
the Earth: Farmers, 
Gardeners, etc. . . . 

Class II. Active Me- 
chanics A broad . . . 
Brick-makers . . . . 
Carpenters and Joiners 
Caulkers and Gravers 

Masons 

Millwrights 

Riggers 

Ship-carpenters . . . 

Slaters 

Stone-cutters 

Tanners 

Class III. Active Me- 
chanics in Shops 

Bakers 

Blacksmiths . . 

Brewers .... 

Cabinet-makers 

Calico-printers . 

Card-makers . . 

Carriage - makers 
Trimmers . . 

Chair-makers . 

Clothiers . . . 

Confectioners . 

Cooks 

Coopers .... 

Coppersmiths . 

Curriers .... 

Cutlers .... 

Distillers . . . 

Dyers 

Founders . . . 

Furnace-men . 

Glass-blowers . 

Gunsmiths . . 

Hatters .... 

Leather-dressers 

Machinists . . 

Millers .... 

Musical-Inst. mkrs 



and 



Number 

of 
Persons. 



31,832 



10,893 
106 

6,150 
180 

1,662 

118 

161 

873 

81 

1,025 
537 



16,576 

471 

2,402 

28 

781 

9 

39 

276 

138 

84 

85 

112 

927 

101 

366 

131 

27 

143 

361 

133 

132 

250 

356 

179 

2,097 

278 

33 



Average 
Age at 
Death. 



65.29 



56.19 
46.85 
53.33 
58.59 
50.33 
59.14 
52.25 
58 53 
40.99 
40.90 
50.36 



47.57 
47.04 
53.26 
47.11 
48.84 
52.11 
48.23 

48.21 
41.77 
56.50 
44.11 
40.82 
59.22 
45.89 
41.50 
39.21 
56.85 
45.17 
42.51 
43.42 
37.88 
48.86 
54.67 
47.23 
41.67 
57.14 
46.73 



Occupations. 



Nail-makers . . . . 

Pail- and Tub- makers 

Painters 

Paper-makers . . . 

Piano-forte-makers 

Plumbers 

Potters 

Pump- and Block 
makers . . 

Reed-makers 

Rope-makers 

Tallow-chandlers 

Tinsmiths . 

Trunk-makers 

Upholsterers 

Weavers . . 

Wheelwrights 

Wood-turners 

Mechanics (not speci- 
fied) 

Class IV. Inactive 
Mechanics in Shops 

Barbers 

Basket-makers . . . 

Book-binders . . . . 

Brush-makers . . . 

Carvers ...... 

Cigar-makers . . 

Clock - and watch- 
makers 

Comb-makers .... 

Engravers 

Glass-cutters . . . . 

Harness-makers . . . 

Jewelers 

Operatives 

Printers 

Sail-makers 

Shoe-cutters ... 

Shoe-makers ... 

Silver or Gold smiths 

Tailors 

Tobacconists . . . . 

Whip-makers .... 

Wool-sorters . . . . 



Number 
of 

Persons. 



174 
5 

1,850 

288 

111 

131 

40 

89 

9 

248 

67 
375 

48 
124 
480 
507 

76 



17,233 

403 

70 

150 

53 

90 

154 

100 

134 

124 

76 

423 

468 

2,138 

717 

217 

362 

9,772 

92 

1,393 

43 

99 

155 



Average 
Age at 
Death. 



41.49 
36.60 
45.07 
48.29 
43.33 
35.53 
56.67 

54.79 
42.78 
58.05 
54.93 
41.05 
39.60 
38.82 
44.95 
56.98 
52.07 

44.84 



43.87 
39.81 
61.63 
40.12 
43.11 
34.00 
38.36 

52.86 
51.38 
40.88 
43.16 
48.74 
40.34 
39.16 
38.62 
53.21 
42.94 
44.61 
46.13 
47 34 
50.35 
42.63 
48.09 



Thirty-third Registration Report of Massachusetts, p. cvi et seq. 



248 



TEXT-BOOK OF HYGIENE. 



Table XXXII (Continued). 



Occupations. 



Class V. Laborers (no 
special trades) . . . 

Laborers 

Servants 

Stevedores 

Watchmen 

Workmen in Powder- 
mills 

Class V I . Factors 

Laboring Abroad, etc. 

Baggage-masters . . . 

Brakemen 

Butchers 

Chimney-sweeps . . . 

Drivers 

Drovers 

Engin'rs and Firemen 

Expressmen 

Ferrymen 

Lighthouse-keepers 

Peddlers 

Sextons 

Soldiers 

Stablers 

Teamsters ...... 

Weighers and Gaugers 
Wharfingers ..... 

Class VII. Employed 
on the Ocean .... 

Fishermen 

Marines 

Naval Officers .... 

Pilots 

Seamen 

Class VIII. MercKts, 
Financ'rs, Ag'ts, etc. 

Agents 

Bankers . .- 

Bank Officers .... 

Boarding-House kprs. 

Book-sellers 

Brokers 

Clerks and Book-kprs. 

Druggists and Apoth- 
ecaries 



Number 

of 
Fersons. 



28,058 
27,382 

389 
76 

193 

18 

7,035 

37 

246 

537 

4 

327 

17 

567 

216 

9 

10 

417 

81 

2,885 

354 

1,282 

24 

22 



8,844 

433 

4 

58 

82 

8,267 



15,977 

376 

49 

151 

75 

73 

198 

3,435 

255 



Average 
Age at 
Death. 



47.41 
47.49 
40.10 
52.09 
50 06 

39.67 

36.29 
34.08 
26.44 
50.19 
34.50 
38.88 
49.29 
38.77 
41.30 
53.78 
60.40 
45.18 
59 94 
28 37 
42.54 
40.35 
60.67 
50.00 

46.44 
42.82 
41.25 
50.00 
60.38 
46.45 

48.95 
46.76 
57 61 
55.14 
47.96 
53 05 
49.58 
35.93 

42.37 



Occupations. 



Gentlemen 

Grocers 

Innkeepers 

Manufacturers . . . 

Merchants 

News-dlrs. and Car'rs 

R. R. Agents or Con- 
ductors .... 

Saloon- and Restau- 
rant- keepers . . . 

Stove-dealers . . . . 

Telegraphers . . . . 

Traders 

Class IX . Profes- 
sional Men . . . . 

Architects 

Artists 

Civil Engineers . . . 

Clergymen 

Comedians 

Dentists 

Editors and Reprtrs. 

Judges and Justices . 

Lawyers 

Musicians 

Photographers . . . 

Physicians 

Professors 

Public Officers . . . 

Sheriffs, Constables, 
and Policemen . . 

Students 

Surveyors 

Teachers 

Class X. Females . 

Domestics 

Dress-makers .... 

Milliners 

Nurses 

Operatives 

Seamstresses .... 
Shoe-binders .... 
Straw-workers . . . 

Tailoresses 

Teachers 

Telegraphers .... 



Number 

of 
Persons. 



1,512 

517 

467 

1,375 

3,927 

27 

318 

299 

12 
5 

2,908 

5,175 

29 

186 

117 

965 

32 

114 

87 

18 

676 

266 

10 

1,166 

45 

437 

158 

288 

86 

495 

3,343 

1,037 

259 

136 

116 

703 

289 

48 

73 

233 

442 

7 



Average 
Age at 
Death. 



C8 42 
47.59 
50.04 
51.23 
54.17 
41.22 

39.85 

40.90 

45.25 
28.80 
48.08 

50.81 
47.07 
44.18 
42.32 
58.57 
37 31 
41.61 
46.68 
64.11 
56.45 
41.59 
36.80 
54.99 
55.93 
55.37 

53.76 
23.23 
51.44 
4179 

39.13 
46 64 
43.36 
39.42 
61.06 
27.82 
46.50 
43.12 
34 83 
47.49 
31.27 
24.43 



the bar have the first and second places respectively. The expec- 
tation of life of physicians is above the average, being nearly 55 
years. Mechanics engaged in active work in-doors may expect to 



OCCUPATIONS PREJUDICIAL TO HEALTH. 249 

live 3.70 years longer than those whose occupation requires them to 
retain a more or less constant position. 

Occupations which are accompanied by the formation of much 
dust, either inorganic or organic, are especially unfavorable. They 
usually produce disease of the respiratory organs, which may eventu- 
ate in phthisis. In the table it is seen that the average age at death 
of stone-cutters was 40.90; of cotton-factory operatives — male, 39.16; 
female, 27.82 ; 2 of cigar-makers, 38.36; and of cutlers, 39.21 years. 
These figures, more or less closely approximate the conditions which 
have been shown to exist in England and on the Continent of Europe. 
In Sheffield, the workmen who grind and polish cutlery, called "dry 
grinders/' are said to suffer from a characteristic pulmonary affection 
termed "grinders' asthma" (emphysema) in the proportion of 69 
per cent, of the whole number employed. The average duration of 
life of the needle-grinders of Derbyshire is 30.66 3 T ears. Among the 
cutlery-grinders of Solingen, in Khenish Prussia, Oldendorff found 
29 per cent, suffering from pulmonary affections, while the average 
age at death of the "dry grinders" was 40.7 years. 

OCCUPATIONS PREJUDICIAL TO HEALTH. 

The diseases of occupations may conveniently be divided into the 
following classes: — 

1. Diseases due to the inhalation of irritating or poisonous 
gases and vapors. 

2. Diseases due to the inhalation of irritating or poisonous dust. 

3. Diseases due to the absorption or local action of irritating or 
poisonous substances. 

4. Diseases due to exposure to elevated or variable temperature 
or atmospheric pressure. 

5. Diseases due to excessive use of certain organs. 

6. Diseases due to a constrained attitude and sedentary life. 

7. Diseases from exposure to mechanical violence. 



2 These figures must be accepted with much reserve. While it is prob- 
able that the average age at death among women engaged in different occupa- 
tions is less than that of men engaged in the same occupations, the figures in 
Table XX, Class X, cannot be used as a basis of comparison. So many women 
are annually withdrawn from the various occupations by marriage, which 
places them under different conditions, that the statistics "of the occupations 
of women in the table are untrustworthy. 



250 TEXT-BOOK OF HYGIENE. 

i. DISEASES DUE TO THE INHALATION OF IRRITATING OR 
POISONOUS GASES OR VAPORS. 

Sulphurous-acid gas is used in various trades as a bleaching 
agent. In the manufacture of straw hats and in the drying or "pro- 
cessing" of hops this agent is extensively employed, and the people 
engaged in these industries frequently suffer from respiratory and 
digestive disorders. These are, however, rarely serious. If free ac- 
cess of air is allowed, the dangers to health in the above employments 
are very slight. 

Nitric-acid fumes may be dangerous to health when inhaled in 
a concentrated form, but very few cases are on record where any 
positively deleterious influence can be traced to this agent. 

Hydrochloric-acid fumes may prove deleterious to the workmen 
in soda manufactories, where the fumes are disengaged during the 
so-called "sulphate process." But the danger is probably slight. On 
the other hand, attention has recently been called to a peculiar effect 
of hydrochloric-acid fumes upon the workmen in fruit-canning es- 
tablishments. The men who seal or "cap" the cans after being filled 
are the ones affected. The lesion has been described by Dr. W. 
Stump Forwood, who says concerning it: "The constant inhalation 
of the fumes of muriatic acid, associated as they are with the lead 
solder, which the busy "capper" neglects to protect himself against, 
soon produces inflammation of the mucous membrane of the nose, 
which finally results in ulceration. With some patients, after the 
removal of the cause and the application of proper treatment, recov- 
ery takes place after two or three months; but with those who have 
a scrofulous taint in their constitutions this ulceration is exceed- 
ingly intractable, and, in spite of all treatment, proceeds for months 
and even years, until the septum is finally perforated. And, strange 
to say, it is the common experience of those who have suffered that, 
as soon as perforation takes place, all the soreness and consequent 
annoyance disappears and the patient recovers, with, of course, a 
permanent opening in the nasal septum." 3 Dr. Forwood adds that 
anointing the nose, both within and without, several times a day, and 
avoidance of the acid fumes as much as possible, will prevent the 
peculiar affection. 

Ammonia rarely causes disturbance of health in workmen 
brought into contact with it. When present in the air in large pro- 
portion it may give rise to serious symptoms. As it is often used to 

8 Phila. Med. and Surgical Reporter, June 30, 1883. 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 251 

prevent the poisonous effects of mercury (q. v.). care should be taken 
that the proportion of the vapor in the air of the work-room should 
not exceed 5 per cent. 

Chlorine gas is very deleterious in its effects upon the workmen 
brought in contact with it in the various industries in which it is 
employed. Nearly one-half of the workmen engaged in the manufac- 
ture of chlorinated lime and in bleaching become affected. 

The respiratory organs are principally attacked. Pneumonia is 
exceptionally frequent. If an affected individual is predisposed to 
consumption the latter disease is soon lighted up, and quickly proves 
fatal. The effect of the inhalation of concentrated chlorine is thus 
graphically described by Hirt 4 : "The workman suffers from violent 
cough and extreme dyspnoea. In spite of the aid of the auxiliary 
respiratory muscles, the entrance of air to the lungs is insufficient, and 
the widely-opened eyes, the pale-bluish color, and the cold perspiration 
plainly show the mortal agony of the patient. With this the pulse 
is small, the temperature decreased. Soon after removal from the im- 
pregnated atmosphere these phenomena disappear, and a few hours 
later the workman is found enveloped in chlorine and hydrochloric- 
acid vapors in his accustomed place in the factory. The attacks seem 
to be but rarely fatal." 

The constant inhalation of an atmosphere strongly impregnated 
with chlorine produces a cachectic appearance, bronchial catarrh, loss 
of the sense of smell, and a prematurely aged appearance. When this 
stage of chronic chlorine poisoning has been reached complete health 
can rarely be re-established, even if the patients be entirely removed 
from the irritating atmosphere. 

Carbon monoxide is often present in the air of gas-works, iron 
smelting-works, and coke or charcoal furnaces. The workmen en- 
gaged in these industries often suffer with diseases of the respiratory 
organs, digestive disturbances, and general debility. Acute poison- 
ing from carbon monoxide is relatively frequent, as already pointed 
out. 5 The prominent symptoms are at first violent headache, dizziness. 
and roaring in the ears. These symptoms are followed by great 
depression of muscular power, nausea, and vomiting. The vomited 
matters sometimes gain entrance into the trachea, and may thus pro- 
duce strangulation. Unconsciousness, convulsions, and asphyxia 
rapidly succeed. Paralyses of the sphincters and of groups of other 



4 Von Pettenkofer und Ziemssen's Handbuch der Hygiene, etc., TI Th. 
4 Abth., p. 30. 

5 See Chapter I, p. 26. 



252 TEXT-BOOK OF HYGIENE. 

muscles are often present. The pulse is at first somewhat increased, 
but soon becomes slower. The respiration is slow and stertorous, and 
the temperature falls from 2.5° to 3° C. (3° to -i° F.). Glycosuria 
often occurs. If death does not occur in the attack, the patient fre- 
quently suffers from great depression, both physical and mental; loss 
of appetite, constipation, and various paretic conditions. 

The slow or chronic form of poisoning by carbon monoxide is 
characterized by headache, dizziness, slow pulse and respiration, nau- 
sea, and sometimes vomiting and purging. Loss of memory and 
diminution of mental activity are also said to be effects of the con- 
tinued inhalation of air charged with carbon monoxide. 

Carbon dioxide is found as one of the constituents of the "choke- 
damp" in mines. There is reason to believe that this is often the 
source of ill health and death in miners, even where the symptoms of 
acute carbon-dioxide poisoning are not present. Hon. Andrew Eoy 6 
says that "it is more insidious than direct in its operations, gradually 
undermining the constitution and killing the men by inches." Diffi- 
culty of respiration and weakness are the only symptoms calling 
attention to the pernicious effects of the gas. Where, however, the 
proportion of carbon dioxide is large, acute poisoning occurs. This is 
manifested by the following symptoms : Loss of consciousness and of 
the power of voluntary motion. In some cases there are convulsions; 
in others the above symptoms are preceded by difficult respiration, 
headache, depression, drowsiness, or psychical excitement. Eecovery 
usually soon follows after removing the patient into a purer atmos- 
phere. 

Vintners, distillers, brewers, and yeast-makers are said to suffer 
from the effects of carbon dioxide occasionally, but serious results 
from this cause are probably very infrequent. 

It may not be amiss to call attention here to another dangerous 
mixture of gases sometimes found in mines, and which is occasionally 
the source of appalling accidents. This is the so-called "fire-damp" 
or light carburetted hydrogen (CH 4 ). When this gas is mixed 
with atmospheric air in the proportion of 6 to 10 volumes per cent., 
the mixture becomes violently explosive if ignited. The danger does 
not cease with the explosion, however, for in this act the free oxygen 
present is consumed in the formation of carbon dioxide, and the 
workmen then die asphyxiated, or from the effects of "choke-damp." 
The dangers from "fire-damp" can be largely averted by thorough ven- 



8 Third Annual Report State Mine Inspector of Ohio. Quoted in Buck's 
Hygiene and Public Health, vol. ii, p. 243. 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 253 

tilation and by the use of the safety-lamp of Sir Humphrey Davy, 
which gives warning of the presence of the gas and permits the work- 
men to escape before the explosion takes place. 

Sulphuretted hydrogen, when present in the air in large propor- 
tion — as, for example, in privy-vaults, cess-pools, and sewers — may 
produce serious or fatal poisoning. Formerly, when vaults were 
cleaned in the primitive way, these accidents were frequent; but at 
the present day, owing to improved methods of removing excreta, 
they are comparatively rare. The precautions advised in a preceding 
chapter 7 should be borne in mind when it is necessary for workmen 
to enter such places. 

The gases resulting from the putrid decomposition of organic 
substances, such as are found in tanneries, glue- and soap-works, and 
similar industries, are popularly believed to give rise to various dis- 
eases. There are no observations on record, however, to show that such 
is the case. As a matter of fact, the workmen engaged in the in- 
dustries mentioned, seem to be exceptionally healthy, and to resist 
to a considerable degree the ravages of phthisis and epidemic diseases. 

Bisulphide of carbon is used in the arts principally in the pro- 
cess of vulcanizing India rubber, and for extracting oils from seeds 
and fatty bodies. The constant inhalation of the vapor of bisulphide 
of carbon produces a train of symptoms to which attention was first 
attracted by Delpech in 1856. The symptoms have been observed fre- 
quently since that time. The following account is from Hirt 8 : — 

"Some days, or even weeks or months, after beginning this occu- 
pation, the workmen complain of a dull headache, becoming more 
severe toward evening. This symptom is soon followed by joint- 
pains, formication, and itching on various parts of the body. A more 
or less troublesome cough is present, but it is not accompanied by any 
characteristic sputa. The respiration is regular, the pulse somewhat 
increased in frequency. During this time certain individuals exhibit 
a marked exaltation of their intellectual powers; they talk more than 
formerly, and show an interest in matters in which they at other times 
show no concern. There is, however, very rarely distinct mental dis- 
ease. The sexual desires are increased in both sexes, menstruation 
becomes irregular, and the urine possesses a faint odor of bisulphide of 
carbon. In this manner several weeks or months pass away. Very 
gradually the physical exaltation disappears, and a profound depres- 



7 Chapter I, p. 28. 

8 Op. cit., p. 66. 






054 TEXT-BOOK OF HYGIENE. 

sion, melancholy, and discouragement succeed, coupled with which 
is often loss of memory. Vision and hearing become less acute, and 
the sexual activity is completely destroyed. Anesthetic spots appear 
on various parts of the body, and numbness of the fingers prevents 
the workman from performing any fine work." 

The disease never proves fatal, but the normal condition of the 
individual is rarely re-established when the disorder has advanced to 
the extreme stages mentioned. 

Iodine and bromine vapors, when inhaled by workmen engaged 
in their preparation, produce symptoms of poisoning which are some- 
times very serious. Acute, iodic intoxication consists in severe laryn- 
geal irritation, headache, conjunctivitis, and nasal catarrh. Oc- 
casionally there is temporary loss of consciousness. Chronic iodic 
cachexia is often found among the workmen. In certain cases 
atrophy of the testicles and gradual disappearance of sexual power 
have been observed. In the manufacture of bromine, a form of bron- 
chial asthma has been observed among those engaged in the establish- 
ment. No symptoms corresponding to those of chronic iodism have 
been observed among the workmen in bromine. 

The inhalation of the vapors of turpentine produces, in a con- 
siderable number of those constantly exposed to them, diseases of the 
respiratory organs, beginning with cough and, at times, resulting in 
consumption. In other cases derangement of the digestive organs, 
strangury, and, in a few cases, bloody urine have been observed. 
Nervous disturbances are rare after the inhalation of turpentine, and 
are limited to headache, roaring in the ears, or flashes of light before 
the eyes. 

Petroleum vapor, when inhaled in a concentrated state, produces 
symptoms similar to those of anesthetics. When exposed for a long 
time to diluted petroleum vapor, workmen sometimes suffer from 
chronic pulmonary catarrhs or from nervous derangements. Among 
the latter are disturbances of mental activity, loss of memory, giddi- 
ness, and headache. These symptoms are, however, rare. More fre- 
quent are pustular or furuncular affections of the skin, which are 
probably due to the direct irritant effect of the vapor. 

Lead poisoning is one of the most characteristic diseases of arti- 
sans. It attacks workmen engaged in the roasting and smelting of 
lead ores ; in the manufacture of white and red lead and of lead ace- 
tate and chromate ; in type-making, in painting, and, in short, in all 
occupations in which the workman is compelled to inhale the vapor 
or dust of lead, or in which it is conveyed in some manner to the 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 256 

digestive organs. It is believed also that it can be absorbed by the 
skin and produce its poisonous effects upon the economy. The aver- 
age duration of life in the roasting and smelting furnaces is 41 years ; 
of painters, as shown by Table XXXII, 54.07 years. Of the latter 75 
per cent, are attacked by one of the forms of lead poisoning, colic 
being most frequent. In the manufacture of white lead more than 
half of the workmen suffer from lead poisoning during the first year, 
lead colic being present in 60 per cent, of all the cases. 

In most sugar-of-lead manufactories 60 per cent, of all the oper- 
atives constantly suffer from some form of lead poisoning. 

Poisoning has also been observed in workmen engaged in the 
manufacture of various pigments of which the acetate of lead is the 
base {e.g., lead chromates). Among type-founders the symptoms of 
lead poisoning are not very rare, and even compositors sometimes 
suffer from lead poisoning. In the latter case the lead must be ab- 
sorbed through the skin in order to produce its effects. 

The various forms in which lead poisoning affects the individual 
are the lead cachexia, manifested by loss of weight, discoloration of 
the skin, the characteristic blue lining along the gums, diminution 
of the salivary secretion, a sweetish taste, and offensive odor of the 
breath; then lead colic, the features of which are well known; lead 
paralysis, the characteristic "wrist'-drop," which requires prompt and 
intelligent treatment, otherwise permanent atrophy of the affected 
muscles often takes place. Among other nervous manifestations of 
the poison is a painful affection of the lower extremities, attacking 
joints and flexor muscles, and remittent in character. At times anes- 
thesia of the skin of the head and neck is present. In rare cases 
serious mental derangement occurs. Other grave nervous lesions, such 
as the so-called saturnine hemiplegia and tabes, are happily extremely 
rare among workmen in the metal at the present day. 

Mercurial poisoning is frequent among the artisans who work 
in the metal. The smelters of the ore suffer severely and in a large 
proportion of the entire number employed. Their average age at 
death is 45 years. Mirror-makers suffer most severely of all artisans 
who come in contact with the vapors of the metal. It is beyond ques- 
tion that the confinement in badly-ventilated work-rooms is largely 
responsible for the poisonous effects of the metal upon this class. 
The special forms in which the poisonous effects are manifested in 
mirror-makers are salivation, mercurial tremor, and nervous erethism, 
but, in addition, a very large proportion suffer from pulmonary con- 
sumption. It is stated that 71 per cent, of the total deaths among 



256 TEXT-BOOK OF HYGIENE. 

mirror-makers (those who coat the glass with the mercury alloy) are 
from phthisis. 

Among women the symptoms are aggravated, and abortion fre- 
quently occurs. Of the children of women suffering from mercurial 
poisoning born living at term, 65 per cent, die within the first year. 

In the Almaden quicksilver mines in Spain a considerable pro- 
portion of the workmen suffer from the milder symptoms of mercurial 
intoxication (gingivitis, salivation, or dryness of the mouth). The 
more severe manifestations (tremor, convulsions, contractures, violent 
muscular pains, paralysis, cachexia) are much less frequent, and lat- 
terly not so severe as they were formerly. 

Fire-gilders, fulminate-makers, and physical instrument makers 
not infrequently suffer from the deleterious effects of inhaling the 
vapor of mercury. Hatters are also liable, to a considerable extent, 
to the poisonous effects of the metal. 9 

It has been found that upon sprinkling the floor of the work- 
room of mirror-makers with aqua ammonia, so as to impregnate the 
atmosphere with ammonia, the bad effects of mercury on the system 
are markedly diminished. Care must be taken, however, not to use 
the ammonia to excess, otherwise the diseases caused by this agent may 
attack the workmen. 

Zinc or copper vapors, or possibly a combination of the two, given 
off from the brass, which is an alloy of these metals, produces a pecu- 
liar train of symptoms known as ''brass-founders' ague." The symp- 
toms are described by Hirt, who has suffered from two attacks of 
the affection himself, as follows 10 "A few hours after attending the 
process of brass-casting, one notices a peculiar, uncomfortable sensa- 
tion over the whole body. More or less severe pains in the back and 
general lassitude cause a discontinuance of the ordinary occupation. 
AYhile the pains appear now here, now there, and are extremely annoy- 
ing, no changes in the pulse or respiration are noticeable. In a short 
time, however, usually after the patient has taken to the bed, chilli- 
ness comes on, which soon increases to a decided rigor, lasting fifteen 
minutes or longer. In the course of an hour or less the pulse now 
reaches a rapidity of 100 to 120 beats per minute. A tormenting 
cough, combined with a feeling of soreness in the chest, comes on. 
In consequence of the repeated acts of coughing, the increasing frontal 
headache produces exceeding discomfort. Soon, however, usually after 



9 Hatting as Affecting the Health of Operatives, L. Dennis, Report New 
Jersey State Board of Health, 1879; Connecticut State Board of Health, 1883. 

10 Op. cit., p. 122. 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 257 

a few hours, the height of the attack is reached; free perspiration 
indicates the stage of defervescence, and during the gradual diminu- 
tion of the symptoms the patient falls into a deep sleep, lasting several 
hours. On awakening, a slight headache and lassitude only remain as 
reminders of the attack." 

It is said that about 75 per cent, of the workmen in brass-foun- 
dries are attacked by this affection ; the attack is liable to be repeated 
at every exposure. 

A chronic form of poisoning is said to occur among zinc-smelters 
after following their occupation for ten to twelve years. It consists of 
hyperesthesia, formication, and burning of the skin of the lower 
extremities, soon followed by alteration in the temperature and tactile 
sensation, and diminution of the muscular sense. Paresis of the lower 
extremities sometimes comes on. The disease has not yet been suffi- 
ciently investigated. 

Aniline vapor is exceedingly poisonous when inhaled in a con- 
centrated state. Hirt describes an acute form which usually results 
fatally: "The workman falls suddenly to the ground; the skin is 
cold, pale ; the face is cyanotic, the breath has the odor of aniline, the 
respiration is slowed, and the pulse increased. The sensation, dimin- 
ished from the beginning of the attack, gradually entirely disappears, 
and death follows in a state of deep coma." 11 There is a milder 
form which comes on after several days of exposure. It is character- 
ized by laryngeal irritation, diminution of appetite, headache, giddi- 
ness, great weakness, and depression. The pulse is rapid, small, and 
irregular. Kespiration is little altered. There is decrease of sensibility 
of the skin. Convulsions may occur, but are usually of short dura- 
tion. 

The chronic form of aniline poisoning is characterized by three 
sets of symptoms: those affecting the central nervous system, the 
digestive tract, and the skin. Among the first are lassitude, headache, 
roaring in the ears, and disturbances of sensation and motion of 
greater or less degree. 

The digestive derangements consist in eructations, nausea, and 
vomiting. 

The cutaneous lesions are eczematous or pustular eruptions, and 
sometimes round, sharply-circumscribed ulcers with callous borders. 

There is no trustworthy evidence that in the manufacture of 
aniline colors poisonous symptoms are produced in the workmen. 



u Op. tit., p. 127. 



268 TEXT-BOOK OF BYGIENE. 

2 DISEASES DUE TO THE INHALATION OF IRRITATING 

OR POISONOUS DUST. 

The inhalation of air containing particles of organic or inor- 
ganic matter has long been accepted as a cause of certain special dis- 
eases of artisans. The diseases so caused are usually limited to the 
pulmonary organs, and consist of acute and chronic catarrh, emphy- 
sema of the lungs, pneumonia, interstitial inflammation of the lungs — 
the so-called fibroid phthisis or pulmonary cirrhosis. 

Coal-dust is inhaled by coal-miners, charcoal-burners, coal-handlers, 
firemen, chimney-sweeps, foundry-men,, lead-pencil makers, etc. 
Chronic bronchial catarrhs are most frequent, while phthisis and 
emphysema are almost absent from the list of diseases affecting these 
workmen. Dr. W. B. Canfield has reported an interesting case of 
pneumonoconiosis in which there was coincident bacillary phthisis. 12 
The table on page 247 shows that the expectation of life of foundry- 
men, furnace-men, firemen, and chimney-sweeps is much below the 
average. 

Metallic dust is inhaled by blacksmiths, nailers, cutlers, lock- 
smiths, file-cutters, cutlery- and needle- polishers, etc. While in this 
class of workmen cases of bronchitis and pneumonia are relatively 
frequent, much the largest proportion surfer from phthisis. A tab n :e 
compiled by Hirt shows that out of the total number of sick in the 
different classes of workmen the cases of phthisis were : — 

62.2 per cent, for file-cutters, 

69.6 " " needle-polishers, 

40.4 " " grinders, 

12.2 " " nailers. 

The Massachusetts table gives the average duration of life for 
blacksmiths at 53.26 years, of nail-makers at 41.49 years, and of cut- 
lers at 39.21 years. The needle-polishers at Sheffield, as already 
stated, have only an average duration of life of 30.66 years. In this 
work and that of grinding knives, scissors, and similar articles, the 
metallic dust is mixed with mineral dust (particles of silica from 
the grindstone). This mixture seems to be much more deleterious 
than metallic dust alone, as shown by the shorter average duration 
of life and the enormous percentage of cases of consumption. 

Mineral dust is inhaled by the workmen in a large number of diff- 
erent industries. The grinders in the ground-glass factories suffer 
most severely. Hirt found the average duration of life in grinders 



12 Trans. Med. and Chir. Fac, Md., 1889. 



DISEASES DUE TO INHALATION OF DUST. 259 

who began this occupation after their 25th year to be 42.50 years, 
while in those who began at the age of 15 the average duration was 
30 years. 

Millstone cutting is also a very dangerous occupation. Peacock 13 
gives the average age of these workmen at 24.1 years. Stone-cutters 
generally suffer frequently from phthisis, probably largely in conse- 
quence of the constant inhalation of the mineral dust produced dur- 
ing their work. The Massachusetts table gives the average age at 
death of these workmen at 40.90 years, while Hirt's table gives a much 
lower age, namely, 36.3 years. Potters and porcelain-makers are ex- 
posed to similar dangers from their occupation, but to a much less 
degree. The table on page 247 gives the average age at death at 56.67 
years — rather a high average. 

Slaters and workmen in slate-quarries suffer in a large propor- 
tion of cases from chronic pneumonia, and die at a comparatively 
early age. 

Masons and carpenters have an average duration of life of 50.33 
and 53.33 years, respectively. One-third of all the diseases from which 
they suffer affect the respiratory organs. 

Ghissenbauer has reported a very interesting series of cases of a 
peculiar inflammatory affection of the diaphyses of the long bones in 
the artisans who are engaged in the manufacture of pearl buttons. 

Gem-finishers are exposed not only to the inhalation of dust, but 
to poisonous gases (carbon monoxide) and vapors (lead). The pro- 
portion of sickness among them is very high. 

Vegetable Dust. — The workmen compelled to inhale vegetable 
dust are those who work in tobacco, cotton-operatives, flax-dressers, 
paper-makers, weavers, wood-turners, millers, and laborers in grain- 
elevators. 

Workmen in tobacco usually suffer, within a few weeks after 
beginning work, from a nasal, conjunctival, and bronchial catarrh, 
which soon passes off, as the mucous membranes seem to become ac- 
customed to the irritation. Nausea is also frequent at first, due 
probably to the absorption of small quantities of nicotine. Females 
exposed to the tobacco-dust usually suffer from digestive and nervous 
troubles. They are also said to abort frequently. 

Dr. R. S. Tracy, 14 as a result of his observations among cigar- 
makers in New York, states that the fecundity of these people is much 



13 Quoted by Merkel, in von Pettenkofer und Ziemssen's Handbuch der 
Hygiene, II Th., 4 Abth., p. 197. 

14 Buck's Hygiene and Public Health, vol. ii, p. 62. 



otfO TEXT-BOOK OF HYGTENE. 

less than the average. Three hundred and twenty-five families 
visited had only 465 children, an average of 1.43 to each family. Dr. 
Tracy is inclined to attribute this to the frequent abortions that occur 
among the females exposed to the inhalation of tobacco-dust. Accord- 
ing to the Massachusetts table, cigar-making is an unfavorable occu- 
pation, the average age at death being 38.36 years. 

Cotton-operatives, flax-dressers, weavers, and workmen in paper- 
mills are subject to various diseases of the respiratory organs. Coetsem, 
as long ago as 1836, described a peculiar pulmonary affection among 
cotton-operatives, which he termed pneumonie cotonneuse. The observa- 
tion does not seem to have been verified by others; at all events, the 
author is unable to find any other record of a similar affection in the 
literature of the subject. Among weavers the mortality from phthisis 
is comparatively high. Among paper-makers Hirt found an average 
duration of life of 37.6 years. ^The people who sort rags are liable to 
a fatal infectious disease, "rag-sorters' disease" (Hadernkrankheit 15 ), 
which resembles in all respects, and is probably nothing less than, 
anthrax. No cases have been reported in this country, but, as the 
importation of rags from abroad is carried on to a considerable extent, 
no apology is believed to be necessary for calling attention to it. The 
"wool-sorters' disease" is similar in its nature. 

Millers suffer in a large proportion of cases from pulmonary af- 
fections, especially bronchial catarrh and pneumonia. According to 
Hirt, 20.3 per cent, of all the diseases of these workmen are pneu- 
monias, 9.3 per cent, bronchial catarrhs, 10.9 per cent, phthisis, and 
1.9 per cent, emphysema. The average duration of life is 45.1 years. 
The Massachusetts table gives 57.14 years — a very much more favor- 
able exhibit. 

The laborers in grain-elevators are compelled to inhale a very 
irritating dust, which causes acute and chronic catarrhs of the re- 
spiratory organs. Dr. T. B. Evans, of Baltimore, has reported a series 
of cases of catarrhal pneumonia in these workmen, which were char- 
acterized by some very peculiar features. Brush-making, according 
to the statistics of Hirt, is a very dangerous occupation. Nearly one- 
half of the deaths among brush-makers are from phthisis, due, in great 
measure, to the inhalation of the sharp fragments of bristles produced 
in trimming the brushes. In the Massachusetts table the average 
duration of life is given at 43.11 years. 



15 See article by Soyka, Realencyclopaedie d. ges. Heilk, Bd. VI, p. 165. 



DISEASES DUE TO POISONOUS SUBSTANCES. 261 

3 DISEASES DUE TO THE ABSORPTION OR LOCAL ACTION 

OF IRRITATING OR POISONOUS SUBSTANCES. 

Arsenic is used in the manufacture of green pigments and for 
various other purposes in the arts. In the preservation of furs and 
in taxidermy it finds extensive use. In the preparation of the pigment 
known as Paris green the workmen are frequently entirely covered 
by a layer of the poisonous salt. The poisonous symptoms occur in 
consequence of the absorption of the poison through the skin or from 
its local action, and but rarely on account of inhalation of vapors or 
dust in which it is contained. The most marked symptoms are 
chronic gastric catarrh, superficial erosions in the mouth, dry tongue, 
thirst, and a burning sensation in the throat. These symptoms may 
continue for months, or even years, and gradually produce a com- 
plete breaking down of nutrition and the vital powers. Violent itch- 
ing skin eruptions of an eczematous character are not infrequent com- 
plications of the internal symptoms. 

Lewin has described a localized pigmentation of the skin in 
workmen (engravers) in silver. The left hand is especially affected. 
The occurrence of the affection is explained by the numerous slight 
injuries of the hands by the gravels tools and the local absorption 
and decomposition of the silver. 

Phosphorus produces two classes of effects in persons subjected to 
its influence. The milder effects are produced by the inhalation of 
the fumes of the substance, and are limited to digestive disturbances 
and diseases of the pulmonary organs. The severer symptoms are 
only observed among the employes in match-factories, and are due 
to the local action of the phosphorus upon the tissues affected. 

The characteristic disease produced by phosphorus is a painful 
periostitis of the lower or upper jaw. The limitation of the affection 
to this locality is believed to be due to the action of the phosphorus 
dissolved in the saliva. The fact that the low r er jaw, with which the 
saliva comes more thoroughly in contact, is most frequently affected 
seems to indicate that this view is the correct one. The disease be- 
gins, on an average, five years after the beginning of the employment. 
Hirt estimates the proportion of employes in match-factories attacked 
at 11 to 12 per cent. The first symptom of the disease is toothache, 
soon extending to the jaw. The cervical glands swell up; the gums 
become reddened and spongy ; abscesses form about the diseased teeth, 
from which large quantities of thin, offensive pus are discharged. 
Examination with a sound reveals carious, nodulated bone. The 



•_>(>2 TEXT-BOOK OF HYGIENE. 

cheeks become swollen, erysipelatous, and may suppurate and discharge 
pus externally. 

Hutchinson has reported a case in which the long-continued in- 
ternal administration of phosphorus as a medicine produced maxillary 
necrosis. 

The destruction of the soft tissues continues until resection of 
the jaw is finally undertaken and the disease checked by surgical in- 
tervention, and removal of the patient from the influence of the per- 
nicious substance. 

Dr. J. Ewing Mears reported 16 16 cases of phosphorus necrosis. 
He concluded "that the antidotal powers of turpentine have been es- 
tablished, both in neutralizing the effects of the poison upon operatives 
during their work and also in the treatment of the early stage of 
the disease. The disease is to be prevented by the adoption of thor- 
ough methods of ventilation, stringent rules with regard to cleanli- 
ness, and the free disengagement of the vapors of turpentine in all 
the apartments of factories in which the fumes of phosphorus 
escape." 

In the manufacture of quinine a troublesome eczema is caused in 
about 90 per cent of the employes. It seems to be due to emanations 
given off from the boiling solutions. It begins with intense itching, 
followed by swelling and the formation of vesicles, which soon burst 
and form crusts. There is considerable fever when the swelling is 
great. It is said that blondes are more frequently affected than those 
of dark complexion. The disease soon disappears if the work is 
given up. 

The workmen engaged in the manufacture of bichromate of 
potassium are said to. suffer from an ulceration of the nasal mucous 
membrane very similar to that already described as due to the vapors 
of hydrochloric acid (p. 250). Kapidty-spreading, deep ulcers are 
also said to form if the bichromate comes in contact with abraded sur- 
faces of the skin. 

The strong alkali handled by tanners frequently produces fissured 
eczemas of the hands, which are painful and often difficult to cure. 

The workmen in petroleum refineries frequently suffer from acnei- 
form or furuncular eruptions. 

Among glass-blowers, syphilis is frequently communicated by an 
infected mouth-piece which is used by the men in turn. 



"Trans. Am. Surg. Association, 1887. 



DISEASES DUE TO EXCESSIVE USE OF ORGANS. 263 

4 DISEASES DUE TO EXPOSURE TO ELEVATED OR 

VARIABLE TEMPERATURE OR ATMOSPHERIC 
PRESSURE. 

Cooks and bakers are exposed almost constantly to a high tem- 
perature, which produces an unfavorable influence upon health and 
predisposes them to diseases of various kinds. The Massachusetts 
table shows that cooks have a much shorter duration of life than 
bakers, although the statistics of both trades are unfavorable. 

The prevailing diseases among cooks and bakers are rheumatism 
and eczematous eruptions, generally confined to the hands, forearms, 
and face. 

Blacksmiths, founders, and firemen suffer from the intense heat 
to which they are exposed, in addition to the inhalation of coal-dust, 
as has already been pointed out. The stokers in the engine-rooms of 
steamships suffer especially from the excessively high" temperature to 
which they are subjected by their occupation. A form of heart- 
weakness, described by Levick as "fireman's heart," is prevalent among 
them. 

Sailors, farmers, coachmen, car-drivers, and teamsters are sub- 
jected to stress of weather, changes of temperature, and storms. They 
suffer frequently from rheumatism, acute bronchitis, pneumonia, and 
Bright's disease. Car-drivers are said also to suffer from painful 
swelling of the feet, varicose veins and ulcers, and mild spinal 
troubles. 17 

Sun-stroke is not confined to any class of artisans, but persons 
who perform very hard labor, especially in a confined atmosphere, 
suffer most frequently. 

The effects of compressed air on workmen in tunnels and deep 
mines have already been referred to. 18 The most serious symptoms 
occur not when the individual is subjected to the increased pressure, 
but when the pressure is too rapidly diminished. 

5 — DISEASES DUE TO THE EXCESSIVE USE OF CERTAIN 

ORGANS. 

The prevalent belief that the overuse of the intellectual facul- 
ties is a frequent cause of mental disease is not borne out by facts. 
Men and women who perform an amount of mental work regarded by 

"A. McL. Hamilton in Report New York Board of Health, p. 444, 1873. 
18 Chapter I, p. 11. 



264 TEXT-BOOK OF HYGIENE. 

most persons as excessive have, in spite of this, a long duration of life. 
There are no exact statistics upon this subject, but Caspar made 
the following estimate of the average duration of life among pro- 
fessional men: Clergymen live Hi>; merchants, 62.4; officials, 61.7; 
lawyers, 58.9; teachers, 56.9; and physicians, 56.8 years. In the 
table on page 248 the figures are somewhat less favorable, although 
corresponding in general with those of Caspar. Hence, it is seen 
that, of professional men, those whose occupation compels the exer- 
cise of high mental powers have a higher duration of life than any 
other class, except farmers and mechanics engaged actively out of 
doors. Those professional occupations only which necessitate a more 
or less irregular mode of life and frequent subjection to physical ex- 
haustion and dangers from contagious disease, such as the work of 
physicians and journalists, make an unfavorable showing in the statis- 
tics. The proposition may be laid down that it is not mental activity, 
however great, but mental worry that tends to the abbreviation of life. 

The occupation of a tea-taster is said to produce a peculiar ner- 
vous condition, manifested in muscular tremblings, etc., which com- 
pels the individual to give up the work in a few years. 

Persons who test the quality of tobacco, an occupation corres- 
ponding to that of tea-taster, are said to suffer from nervous symptoms 
which may include amaurosis and other grave affections. 

Those persons who are compelled to use their eyes constantly 
upon minute objects frequently suffer from defective vision. So en- 
gravers, watch-makers, and seamstresses are liable to near-sighted- 
ness, amaurosis, and irritation of the conjunctiva. Public speakers 
and singers frequently suffer from catarrhal or even paretic condi- 
tions of the throat, which usually disappear on relinquishing the 
occupation for a time. 

Telegraph operators and copyists suffer from a peculiar convulsive 
affection of the fingers, called "writers' cramp." Cigar-makers are also 
said to suffer from a similar cramp of the fingers used in rolling cigars. 
Performers on wind instruments are liable to pulmonary emphysema, 
on account of the pressure to which the lungs are frequently subjected. 
Boiler-makers often suffer from deafness, in consequence of their con- 
stant existence in an atmosphere in a state of continual violent vibra- 
tion. The affection is generally recognized as ''boiler-makers' deaf- 
ness." Dr. C. S. Turnbull has reported several cases of "mill-opera- 
tives' deafness." Its characteristic is an inability to hear distinctly 
except during a noise. 



DISEASES DUE TO MECHANICAL VIOLENCE. 265 

6 DISEASES DUE TO A CONSTRAINED ATTITUDE AND 

SEDENTARY LIFE. 

It is probable that the large mortality and morbidity rate of per- 
sons whose occupations keep them confined within doors are due, next 
to the defective ventilation, to the constrained attitude which most 
of them necessarily assume. Thus, carvers, book-binders, engravers, 
jewelers, printers, shoe-makers, book-keepers, and cigar-makers all 
have a low average duration of life. It is found, likewise, that many 
of these artisans suffer most from pulmonary and digestive troubles, 
among the former being phthisis, and among the latter constipation, 
dyspepsia, and hemorrhoids. 

7 DISEASES FROM EXPOSURE TO MECHANICAL 

VIOLENCE. 

It will be seen, by reference to the table on page 248, that all 
persons whose occupations involve an intimate contact with machinery, 
and in the pursuit of which accidents frequently happen, have a short 
duration of life. Persons liable to these dangers are machinists, 
operatives in factories, workmen in powder-mills, baggage-masters, 
brakemen, drivers, engineers, firemen, and other workmen on rail- 
roads. Aside. from the diseases to which some of these classes are 
liable in consequence of exposure to variable atmospheric conditions, 
the grave accidents to which they are so frequently exposed render 
their occupations extremely dangerous. Brakemen on freight rail- 
roads, for example, are classed by insurance companies as the most 
hazardous "risks," and some companies refuse to take them at all. 
The table on page 248 tends to confirm the conclusion of the insurance 
companies, for, excluding the class of "students," which, for manifest 
reasons, cannot be used as a comparison, brakemen have the shortest 
average duration of life of all the occupations noted in the table. 



II 



QUESTIONS TO CHAPTER IX, 
INDUSTRIAL HYGIENE. 

How may various occupations induce disease? Are such diseases always 
necessarily due to the occupations, or are there incidental factors that might 
be avoided? What classes of men have the greatest expectation of life? What 
occupations are especially unfavorable to health? What diseases do they 
usually produce? How may diseases of occupations be conveniently classified? 

What disorders are liable to be produced by the inhalation of the gases 
of the mineral acids? What peculiar symptoms may be due to the constant 
inhalation of the fumes of hydrochloric acid? What effect has ammonia gas? 
What disease is frequently due to the constant inhalation of chlorine gas? 
What other disease is also especially favored by it? What are some of the 
symptoms produced by the gas in a concentrated state? By the constant 
inhalation of the gas? 

In what occupations is carbon monoxide often given off to the air? 
What are some of the acute symptoms produced by it? What of the chronic 
poisoning by gas ? Is there any evidence that carbon dioxide in small amounts 
may cause symptoms of chronic poisoning? What are some of the manifesta- 
tions in cases of acute poisoning by this gas? What other gas is often found 
in mines, and how may it be dangerous to life? How may its dangers be 
avoided? 

Where may sulphuretted hydrogen be found in quantities sufficient to 
produce serious results? What are some of the evil effects due to the inhala- 
tion of the vapor of bisulphide of carbon? Of iodine and bromine? Of tur- 
pentine? Of petroleum? 

In what occupations are the laborers subject to lead poisoning? What 
effect has it on the duration of life? In what forms may lead poisoning mani- 
fest itself? What proportion of workers in lead are affected by it? 

What proportion of workers in mercury are affected by that metal? 
To what disease are mirror-makers especially prone? What are some of the 
symptoms of mercurial intoxication? What peculiar effect has the metal 
upon female laborers and their children? How may the bad effects of mer- 
cury be diminished? 

What are the symptoms of "brass-founders' ague"? Is it common among 
the class indicated? What symptoms may indicate chronic zinc poisoning? 

What are the symptoms of acute poisoning by aniline vapor? What 
peculiarities characterize chronic aniline poisoning? Are these or others 
liable to be produced in those employed in the manufacture of aniline colors? 

(266) 






QUESTIONS TO CHAPTER IX. 267 

What class of diseases is especially apt to be caused by the continued 
inhalation of dust? What is the most common affection among those who 
inhale coal-dust in large quantities? From what pulmonary disease are they 
exceptionally free? Is the expectation of life among this class of workmen 
high? What diseases seem to be especially favored by the inhalation of 
metallic dust? Which of these is the most frequent? What is the effect of 
a mixture of metallic and mineral dust? What occupations have a high mor- 
bidity and mortality from phthisis? What from chronic pneumonia or other 
pulmonary affections? To what peculiar affection are pearl-button-makers 
subject? 

What workmen habitually inhale vegetable dust? What disturbances 
are due to the inhalation of tobacco-dust? What effect has it on fecundity, 
and why? 

To what diseases are workers in cotton and flax subject, and from which 
one especially is the mortality high? What is the average duration of life 
among paper-makers? To what disease are rag- and wool- sorters liable? 
From what affections do millers and workers in grain-elevators suffer? Why 
is the mortality from phthisis so high among brush-makers? 

What substances are liable to cause disease by absorption or local action ? 
What are some of the symptoms common to those working with arsenic? 
What two classes of effects are observed among those exposed to phosphorus 
vapors? To what is each class due? What may be used as a preventive and 
antidote to such eases of phosphorus poisoning? What malady is associated 
with the manufacture of quinine? What other substances may produce eczema 
or ulceration in their preparation or manufacture? 

What diseases are favored by continued exposure to high temperatures? 
In what occupations are such disturbances accordingly prevalent? What 
class of laborers are subject to sudden changes or to extremes of temperature? 
What are some of the maladies that may be, in part, traced to such cases? 
What are the effects of compressed air upon laborers in it, and when are 
they manifested? 

What diseases or disturbances may be due to the excessive use of certain 
organs? Is there any evidence that excessive mental activity leads to men- 
tal disease? What is a factor in the production of the latter? Why is the 
mortality-rate so high among those who follow sedentary or in-door occupa- 
tions? What disturbances are most common to these pursuits? In what 
occupations are the laborers especially liable to mechanical violence? Is the 
average duration of life of such workmen low or high? 



CHAPTER X. 

MILITARY AND CAMP HYGIENE. 

Hygiene applying especially to military life has made great ad- 
vances in recent years, and as the causes of epidemic diseases formerly 
considered the inevitable accompaniment of war have one by one been 
made manifest, many fatal camp maladies have lost in the eyes of the 
medical officer much of their former menace. 

The soldier of the present day has many more comforts than 
before. Each year sees the adoption of improvements in food, shelter, 
or clothing, while the care of the sick and wounded in active service 
approaches more nearly an ideal standard. 

i THE RECRUIT. 

The raw recruit, sometimes awkward and slovenly, often unpre- 
possessing in appearance, is the material from which armies are made. 

The selection, therefore, of men capable physically and mentally 
of being trained into disciplined soldiers lies at the very foundation of 
military hygiene. At first glance nothing would seem to be easier 
than for a physician to detect unsoundness in an applicant for a 
soldier's life. As a matter of fact, experience and knowledge of mil- 
itary conditions are requisites to properly select recruits. Many de- 
fects of structure in no way affecting the actual bodily health, or, 
from the standpoint of the examiner of life insurance, the expecta- 
tion of life, are properly considered bars to enlistment. A man suffer- 
ing from or predisposed to disease is of course at once rejected, but 
the accepted recruit must have the free use of all of his limbs; his 
hearing, vision, and speech must be perfect; he must be of ample 
chest measurement and justly proportioned. An inquiry must also 
be made into his personal and family history, and persons presenting 
the appearance of tramps, vagabonds, or hard drinkers, or manifesting 
lack of intelligence, are to be rejected, even if apparently able-bodied. 

Only under very exceptional circumstances are recruits under 
21 years old accepted in the United States army. Some medical 
officers of experience think that for tropical service the minimum age 
should be even greater, and that an ideal army for such service would 
be composed of men between 25 and 45 years of age. 
(268) 



THE TRAINING OF THE SOLDIER. 269 

The height of a recruit is at present fixed at 5 feet 4 inches as 
a minimum for all branches. 

The maximum height for cavalry is 5 feet 10 inches, and the 
maximum for artillery and infantry is governed by the rule for 
weight, as follows: — 

The minimum weight for all recruits is 124 pounds, except for 
the cavalry, in which enlistment may be made without regard to a 
minimum weight if proportions and chest-measurements are satis- 
factory. The maximum weight for artillery and infantry is 190 
pounds, for cavalry and light artillery, 165 pounds. 

Up to and including the height of 67 inches the recruit should 
weigh 2 pounds for every inch. The same rule applies to men of 
greater height, but with the addition of 5 pounds for every inch 
above 67. 

The difference between the chest-measurement at inspiration and 
expiration should be at least 2 inches in men of 67 inches in stature 
or below, and 2% inches above that height. 

These rules are considered to give a fair standard of physical pro- 
portions, but a slight deviation from them is allowed in specially de- 
sirable recruits. Vaccination of all accepted men is compulsory. 

2 THE TRAINING OF THE SOLDIER. 

The preliminary drill of a recruit is generally purely calisthenic. 
The "setting-up drill" of the United States army is admirably 
adapted for its purposes, to render the recruit supple and alert, quick 
to respond to the word of command, and to give him an upright and 
graceful carriage. Although especially intended for the recruit, a 
certain amount of this exercise is given to all soldiers throughout their 
entire period of service. 

All the muscles of the body are brought into play, and the effects 
of the exercise on the muscular development of young and ungainly 
recruits are soon seen. 

The movements in the manual of drill with the rifle have the dis- 
advantage of being largely unilateral, and when once learned are so 
automatically performed that the calisthenic benefit of bodily exercise 
is not to any extent gained thereby. 

Exercises of agility are practiced by cavalrymen and light artil- 
lerymen especially. The skill attained in fancy horsemanship by 
many of the soldiers is only excelled by the best professional circus- 



270 TEXT-BOOK OF HYGIENE. 

riders. For infantry, wall-scaling and the crossing of obstacles while 
carrying arms and equipment are taught. 

Exercises of endurance consist of practice marches with full 
equipment, and lastly there is the special training in the use of the 
implements of war. 

The defective recruit who has been improperly selected, very 
soon, under military training, shows his incapacity for the service. 
A man with flat-foot plays out on the march ; with a crippled thumb 
he can never properly handle his rifle; with even a slight defect in 
hearing he spoils the manual of his company by inability to properly 
catch the word of the drill-master. These are samples of some of the 
commoner defects which are often overlooked in apparently able- 
bodied men by the average physician examining men for the military 
service, and which must be specially guarded against when war re- 
quires the enrollment of thousands of volunteers, and when inex- 
perienced medical examiners must of necessity be relied upon. 

3 THE FOOD OF THE SOLDIER. 

An. army ration is one day's allowance for one soldier. The 
rations for an organization are drawn in bulk for periods of days, 
usually ten, except the fresh meat, which is delivered on certain days 
by the contractor, and fresh bread, which is drawn daily. The super- 
vision of the company mess and the management of the use of the 
rations are within the province of the company commander, and are 
by no means his least important duties. 

The ration of the United States army is the most liberal and 
diversified of any in the world. 1 Each soldier is entitled to a per diem 
allowance as follows : — 



1 A new ration order, issued by the War Department April 3, 1908, mate- 
rially improves the already excellent U. S. ration. The allowances of the 
standard meat, bread, and vegetable components are not greatly changed, but 
the selective articles are more diversified, giving greater latitude to issuing 
and purchasing officers, and being adapted to different markets and conditions 
of service. Salt pork and salt beef have been stricken from the list. Canned 
meats are allowed when impracticable to furnish fresh. Turkey and chicken 
are allowed on national holidays. Half an ounce of butter or oleomargarine 
is added to the ration, and a like amount of evaporated cream for the soldier's 
coffee. The vegetable ration is increased to 20 ounces. There are some other 
minor changes, and, in addition to the usual or "garrison- ration," the allow- 
ances to be issued under special conditions are listed at length, as in the "field 
ration," the "haversack ration," the "travel ration," the "emergency ration," 
and the "Filipino ration" for the use of the native scouts in the Philippine 
Islands. 

The whole order is too long to insert in a short chapter on military 
hygiene, but all the really important changes are here given. t 



THE FOOD OF THE SOLDIER. 271 

Table XXXIII. 

Meat Components. 

Fresh beef 20 oz. 

Or fresh mutton 20 oz. 

Or bacon 12 oz. 

Or pork 12 oz. 

Or salt beef 22 oz. 

Or dried fish (cod) 14 oz. 

Or fresh fish (cod whole) 18 oz. 

Or pickled fish (mackerel ) 18 oz. 

Or canned fish (salmon) 16 oz. 

Bread Components. 

Flour 18 oz. 

Or soft bread 18 oz. 

Or hard bread 16 oz. 

Or corn meal 20 oz. 

Vegetables and Miscellaneous. 

Potatoes 16 oz. 

Or potatoes 80 per cent, and onions 20 per cent 16 oz. 

Or potatoes 70 per cent, and canned tomatoes 30 per cent.. 16 oz. 

Dried fruits ( various ) 2 oz. 

Sugar 2% oz. 

Or molasses ." ' !%5 gill. 

Or cane syrup i%5 gill. 

Coffee (green) 1% oz. 

Or coffee (roasted) 1%5 oz. 

Or tea ( green or black ) % 5 oz. 

Vinegar 8 /> 5 gill. 

Salt '..-...; i% 5 oz. 

Pepper ^5 oz. 

Baking powder (in field only) x %5 oz. 

Soap !% 5 oz. 

Candles %5 oz. 

The nutritive value of a ration, of course, varies greatly, accord- 
ing to the choice made from the selective articles in the foregoing 
list. 

The most nutritive combination that a soldier can get in any one 
day consists of 61 ounces of food, containing, by metric weight, 97.79 
grams of fat, 600.74 grams carbohydrate, 164.27 grams proteids, with 
a total fuel value of 4061 calories. If the selection is made from the 
least nutritive articles of the ration, a soldier may receive food allow- 
ance for one day of as low a value as 2321 calories. 

The field ration for service in campaign consists of bacon, hard 
bread, beans, dried fruit, sugar, coffee, etc., with fresh vegetables 
when obtainable. It has a value, even without the vegetables, of 4448 
calories. 

The German army issues rations of the following values 
(Atwater) : — 



272 TEXT-BOOK OF HYGIENE. 

German ration, peace footing 2800 calories. 

ordinary war footing 3095 " 

" extraordinary war footing 3985 " 

and the fuel value of the diets of men performing hard labor in civil 
life have been estimated as follows: — 

Active muscular labor, Atwater (American) 4060 calories. 

Men at hard work, Voit (German standard) 3370 " 

Active laborers, Playfair (English standard) 3630 " 

The ration of the United States army is thus seen to be superior 
to the highest German ration, and to equal or exceed the accepted 
standard diet of working men in civil life. 

In Alaska the already liberal army ration is increased still fur- 
ther; vegetables by one-half, bacon one-third. 

In the Philippine Islands the regular ration is issued, and 
although the question of a special diet possibly better adapted for 
tropical climates has been much discussed, the consensus of opinion 
of officers, both staff and line, is against changing an allowance which 
has proved so satisfactory. 

Each article of the ration has a fixed money value, which may be 
drawn instead of some of the articles, and expended for the purchase 
of food not in the ration. 

The money so acquired becomes a part of the "company fund," 
along with money received as the organization's share of profits of the 
post exchange, the post bakery, etc. With a company fund judiciously 
expended, and with extra vegetables from gardens cultivated at the 
station, organizations in the United States army generally fare excel- 
lently. Recent improvements in field cooking-ranges and ovens make it 
now possible to serve as good meals in stationary camps as in permanent 
posts. Much of the sickness and consequent inefficiency of hastily- 
raised bodies of troops is due to lack of knowledge in drawing, man- 
aging, and cooking the ration. No training is, therefore, more valu- 
able for organizations of the National Guard that that received in 
the summer camps, where, under army regulations, they assume the 
entire management of their own subsistence. Company cooks are now 
very well paid, and properly so, as on their efficiency the health of the 
command very largely depends. 

4 THE CLOTHING OF THE SOLDIER. 

With due regard to economy, the uniform of the soldier must be 
well made and of good material. In the United States army, the blue 
uniform with brass buttons is now only used in garrison and for dress 



THE CLOTHIXG OF THE SOLDIER. 273 

purposes. In common with most of the large foreign nations, and 
owing to the great range of modern firearms, a color inconspicuous 
and harmonizing with the landscape has been adopted for field work. 
To an enemy armed with modern rifle, using smokeless powder, troops 
uniformed in colors contrasting strongly with their surroundings offer 
a splendid target and ar£ at a great disadvantage. Even the glint 
of sunlight on polished buttons or weapons at a distance of several 
miles may attract the enemy's attention and result in increased mor- 
tality or strategical failure. The present field uniform is of an olive- 
drab or khaki color with buttons and metallic ornaments in bronze. 
It is made in different weights, for temperate, arctic, and tropical cli- 
mates, and does not easily show the effects of wear. 

Underclothing, head-covering, and foot-gear are of good quality, 
much improvement having been made in the shoes furnished by the 
Quartermaster's Department. With infantry the care of the feet is 
a paramount consideration; well-fitting shoes and stockings are, 
therefore, of the utmost importance. 

The field uniform may be rendered tolerably waterproof by lano- 
lin or one of the other modern processes, and this is required by regu- 
lation. For protection against heavy rains and for use when sleep- 
ing on the damp ground, the soldier is provided with a rubber poncho, 
or blanket. 

So much fault was found with the method of carrying the blank- 
ets, extra clothing, etc., in a knapsack strapped on the back, and also 
with the very heavy cartridge belt around the waist, that a radical 
change has been found necessary in the "heavy marching order" 
equipment. 

An ammunition-belt is still used around the waist, but is sus- 
pended by straps from the shoulders. Additional ammunition, when 
necessary in field service, is carried in a bandolier" worn diagonally 
across the body. To the suspending straps are attached the canteen, 
filled with water, and the haversack, containing rations and mess- 
implements. Blankets, poncho, extra clothing, etc., are worn in a 
roll over the shoulder. The total weight which must be carried by a 
soldier in heavy marching order, including his clothing, is about 70 
pounds, a load far too heavy to allow celerity of movement, and prob- 
ably distinctly injurious to health. An ordinary day's march or two 
may be made with full equipment without undue fatigue, especially 
if the destination is a camp of some permanence, where the troops 
may rest several days. In very active service a reduction in the 
weight of the equipment may be required and must first fall upon the 

18 



274 TEXTBOOK OF BYGIENE. 

extra clothing carried in the blanket roll. By discarding overcoat, 
extra clothing, one blanket, and either the rubber poncho or shelter- 
tent half, the roll is brought down to its lowest limit, the total weight 
carried being then below 50 pounds. The present method of adjust- 
ing the load of the foot soldier is a great advance on the former way, 
and allows even the full equipment to be carried with much less 
fatigue than before. 

5 — THE DWELLING OF THE SOLDIER. 

At permanent military stations the troops are housed in bar- 
racks — buildings either of one or two stories, constructed of stone, 
brick, or wood. A barrack for a single organization should contain 
large dormitories or squad-rooms, suitable bed-rooms for non-commis- 
sioned officers and the cooks, a large recreation- or day- room, kitchen, 
store-room, lavatory, and an office for the company commander and 
the first sergeant. In the United States army, the barracks con- 
structed in recent years leave little to be desired, from the sanitarian's 
standpoint. At some of the older stations, buildings originally hastily 
or cheaply constructed have been added to or altered from year to year, 
and are, in consequence, more or less unfitted for military occupancy. 
Such posts, however, are either being gradually abandoned or else, 
it having been decided that the location is to be permanent, entirely 
new buildings are in course of construction or provided for. There is 
no single accepted model in the United States army for barracks. A 
number of plans have been approved for buildings of various mate- 
rial and design. 

The use of the buildings, whether for infantry, cavalry, or ar- 
tillery, the climate and soil of the proposed location, the cost and 
availability of material, must all be taken into consideration in so 
large a country as the United States. Some of the modern barracks 
are double and house two organizations, but single barracks present 
so many advantages that they have been very wisely adopted. For the 
proper location of barracks, a dry and well-drained site is required, 
with exposure on all sides to sunlight and air. The building materials 
should be the best of their kind, and especial care taken to avoid damp- 
ness. A dry cellar under the whole building, when the nature of the 
soil permits, is a great advantage. In tropical countries the first 
floor should be raised several feet from the ground, to permit a free 
circulation of air beneath the building. Ample window-space and 
broad verandas are also important features in hot climates, where the 
soldier's life is passed almost entirely in the open air. 

Ventilation in the tropics presents no difficulties, but in cold 



THE DWELLING OF THE SOLDIER. 275 

climates the dormitories of soldiers are apt to be either imperfectly 
heated or badly ventilated. 

The minimum initial air-space per man should never be below 
600 cubic feet, and this amount is not enough unless the means 
of ventilation are exceptionally good. One thousand cubic feet should 
be looked upon as the ideal allowance per man, and approached as 
nearly as economy will permit in the construction of new barracks. 
Each bed should also be allowed a minimum floor-space of 50 square 
feet. In the construction of barracks the same rules apply as in the 
building of any habitation intended for the use of a large number of 
occupants. 

Wood is to be avoided as far as possible, and fire-proof material 
substituted. 

Floors should be of hard wood, tongued and grooved, and laid 
upon iron beams and cement. No wood should enter in the construc- 
tion of the walls, the inside finish must be smooth, and all corners 
rounded. 

Plumbing must be exposed throughout its course, and it is a good 
plan to have the lavatory and water-closets in a detached structure 
reached by a covered way, although when properly constructed and 
cared for there is no great objection to their location in the base- 
ment. 

In France, barracks built according to the designs of M. Toi- 
let have proved very satisfactory, but seem not to have been univer- 
sally adopted on account of expense. These are built on the pavilion 
plan; the first floor is elevated above the ground, on which a layer 
of cement has been placed. The walls are double, with air-space be- 
tween, and the materials fire-proof. They are said to be very dry, well 
ventilated, and easily heated. In the British army, pavilion barracks 
of simple construction are also much used. A pure and simple water- 
supply and perfect disposal of excreta and wastes are, of course, ab- 
solutely essential to health of troops in garrison. 

At some sea-coast forts, United States troops still inhabit case- 
mates, but it is likely that in a few years the last of such extremely 
unhygienic quarters will be abandoned. Casemates are damp, dark, 
and badly ventilated, and the inhabitants are apt to suffer from rheu- 
matism and troubles of the respiratory organs. 

On the march and in camp the soldier is sheltered in tents, of 
which the simplest form is the shelter-tent. Each soldier has as a 
part of his personal equipment one shelter-half and a light, jointed 
pole. By buttoning together their two pieces a small tent is formed, 
beneath which two men can crawl and keep themselves and equipments 



276 TEXT-BOOK OF HYGIENE. 

dry, except in driving rain-storms. For expeditions when camp is 
made every night, it is extremely useful, but it affords only a slight 
protection in very inclement weather or in extremely cold climates. 

The conical wall-tent now used is a modification of the old Sibley 
tent It is circular, with a perpendicular wall three feet in height, 
surmounted by a cone open at the top. The top may be covered in 
whole or in part by a canvas hood, which prevents the entrance of 
rain, but which can be opened for ventilation. There is a single cen- 
tral pole standing upon an iron tripod, between the legs of which a 
stove may be placed in cold weather. 

This tent is economical, protects well from even driving rain, 
and is especially comfortable for field work in winter. 

The floor-space is 212 square feet, and its capacity 1450 cubic 
feet. 

According to the strict letter of the regulations, 20 foot-soldiers, 
or 17 cavalrymen with their saddles, etc., are supposed to occupy one 
tent. Not more than half this number can, however, be comfortably 
housed, and, as a matter of fact, the tentage issued to a command 
is never so strictly limited. Objections to the conical tent are that 
it is very uncomfortable in hot weather, and that the part of the floor- 
space on which a full-grown man may walk erect is very limited. 

The common or "A" tent is oblong, has a wall of 2 feet, is 6 
feet 10 inches in height, and its floor-space is 57 square feet. Its 
capacity is only 250 square feet, and the ridiculously excessive num- 
ber of six infantrymen or four mounted men is assigned to it by regu- 
lation. In a permanent camp, two men only can be perfectly comfort- 
able in this tent, but they may be made exceedingly so, as there is 
ample space for their field cots and all their equipments. 

The officers' wall-tent is very comfortable for two occupants, as 
it is much larger than the common tent, and is provided with a 
canvas fly or second roof, which protects perfectly from rain and 
makes the tent much cooler in hot weather. 

The hospital tent is the largest and by far the most comfortable 
tent used in the army. It is a wall-tent with a fly, and it opens at 
both ends, so that several tents may be joined to make a ward for the 
sick. The tent is 14 by 15 feet floor-space, and 12 feet high, accom- 
modating very comfortably six patients and their cots. Hospital 
tents, though intended only for the sick, have been sometimes issued 
to troops in more or less permanent camps in the tropics. When 
floored and framed, the occupants are as well off as when in barracks. 

All tents should be properly ditched to prevent flooding from 
rain, and they should be frequently struck and exposed, inside out, 



SANITARY CARE OF CAMPS. 277 

to the sun-light. The ground covered also must be occasionally 
cleaned and sunned. Movable floors and frames for tents increase 
very much the comfort of camp life, and should always be constructed 
in camps of any permanence. 

The interior of a tent is apt to become stuffy and damp, so that 
the walls should always be kept elevated in good weather during the 
daytime, allowing the greatest possible circulation of air. 

When camps are to be occupied for many months, especially 
in winter, it is always advisable, on the score of economy as well as 
health and comfort, to shelter the soldiers in huts or cabins instead 
of tents. Huts may be constructed of logs plastered with mud, or 
roughly-dressed lumber lined and roofed with canvas. During the 
Spanish-American war, several large general hospitals on the pavilion 
plan were put up, for temporary use, of unpainted wood covered 
with tar-paper. There are in the market also several patterns of 
portable dwellings, which can be taken apart and shipped in packages 
of convenient size, portions of the floors .and walls being used for the 
packiog boxes. It is possible that for armies of occupation such mov- 
able houses may prove practicable and economical. 

6 SANITARY CARE OF CAMPS. 

Sanitation in well-built posts is a simple matter enough, merely 
requiring that existing excellent conditions be maintained. In camp 
life the health of the troops depends on most minute attention being 
given to small things. Military discipline is at the bottom of good 
hygiene, and the custom of trained soldiers to keep every article in 
its place, and always ready for inspection, is a powerful factor towards 
preserving their health. All rubbish must be daily removed and 
burned. Kitchen garbage and fragments of food from the mess must 
be deposited in covered receptacles periodically emptied and cleaned. 
The ground around the tents is to be kept scrupulously clean, and to 
this end it is better that all shrubbery be cleared away, although 
shade- trees should not be harmed nor grass disturbed. Waste mate- 
rial must never be dumped near the camp ; if not destroyed, it must 
be carried far away. The camp kitchens must be sheltered from 
rain, and the food screened from flies and dust. A pure water-supply 
having been obtained, the source, the receptacles, and the drinking 
vessels must be kept uncontaminated. The proper disposal of excreta 
in a large camp is a most important subject, and often presents many 
difficulties. The simplest method is to dig latrine pits for each or- 
ganization, and cover the excreta therein, at frequent intervals, with 
some of the excavated earth; but most medical officers now condemn 



278 TEXT-BOOK OF HYGIENE. 

the use of the privy pit for any but marching commands, or camps 
of very short duration. Unless there is a constant watch kept, some 
excreta is always exposed long enough to attract swarms of flies, which 
afterward contaminate food in the kitchens and at the mess. The 
earth, unless perfectly dry, does not deodorize efficiently, and if the 
ground-water is high the pits cannot be made of sufficient depth. The 
use of quicklime in and around the pits is advocated, or, better still, 
they may be burned out every day with dry grass or leaves saturated 
with kerosene. A sanitary field latrine authorized by the War De- 
partment in 1899, and since used at many permanent camps, has 
proved so satisfactory that its use to the exclusion of any other 
would seem always advisable. The latrine consists of a trough made 
of stout galvanized iron 14 feet long, 22 inches wide at the top, 
parabolic in cross-section, and with a maximum depth of 18 inches. 
This is set in a wooden frame, used as a crate in transportation. One 
end of the trough is elevated 4 inches from the level. It is covered 
by a seat which may be easily lifted, and has places for seven men. 
The holes are cut away so that the seat cannot be soiled either in front 
or rear, and a slanting board arranged so that the men cannot stand 
on the seat. For use, the trough is filled with water to a depth of 6 
inches at its lower, and 2 inches at its upper end, and one-sixth of a 
barrel of lime is mixed in daily. Toilet paper must be used, and the 
contents of the trough stirred vigorously with a paddle three times 
a day. No other care is necessary, as the apparatus is clean, odorless, 
and does not attract flies. A gutter to serve as a urinal, kept sprinkled 
with lime, is connected to the trough at its upper end. The latrine 
is covered with a rough wooden shed, the dimensions of which, even 
to the various boards comprising it, are specified in orders. To empty 
the trough, an odorless excavator is necessary: a large, tight, barrel- 
shaped tank on wheels, with a powerful suction-pump. One such ex- 
cavator is enough for many latrines, and the troughs must be 
emptied daily. The mixture of milk-of-lime and faecal matter is 
quite harmless and has considerable fertilizing value. In future no 
large stationary camp should be established in the United States 
without this method of excreta disposal, which is the cheapest and 
most effective yet devised. As there is always difficulty in compelling 
the soldiers to use the sinks for urination, especially at night, it is 
advisable to have galvanized iron cans for urine placed at intervals 
in the company street, sprinkled inside with lime, to be removed and 
cleaned in the morning; otherwise the ground near the tents will be 
contaminated with urine. 



CAMP DISEASES. 279 

In camp sanitation the voluntary cooperation of the soldier can 
never be relied upon. Close inspection, with rigid enforcement of 
sanitary rules by commanding officers and medical officers is absolutely 
necessary. 2 

7 CAMP DISEASES. 

When the causes of disability and death in the military service 
are looked into, it is found that disease is a far greater factor in 
both, than wounds and injuries. In even the bloodiest wars the 
total number killed outright or dying from wounds never equals the 
number dying from sickness. 

Under the name of "camp diseases" may be included all the 
maladies to which soldiers are especially liable in field-work or war. 
All of these exist in civil life, but the conditions of camp life are 
particularly favorable to their widespread prevalence. 

Dysentery and Diarrhea. — Troops in campaign have always been 
especially subject to dysentery and diarrhea. In the civil war about 
one-fourth of all deaths in the army were from these two diseases. 
Even now, with the many advances made in medical knowledge, and 
especially in military hygiene, intestinal diseases rank first in the 
United States army as causes of disability and death. In 1902, for 
every 1000 men there were 290.61 admissions and 2.53 deaths from 
intestinal complaints. In actual war the rates greatly increase. 

The causes of intestinal troubles in trcops may be summed up 
as impure water, badly cooked food, exposure to wet and cold, and 
lowered vitality due to other diseases, such as malaria. 

Among troops in the tropics the most serious disease of this 
nature is dysentery, due to the presence of an animal organism, the 
Ameba dysenteria?, in the intestines. The disease is generally insidi- 
ous in its approach and exceedingly difficult to cure. Not only has it 
caused the loss of many valuable lives in the service, but numbers 
of soldiers have been discharged for disability, as incurable, to live 
lives of semi-invalidism and probably to die finally of exhaustion, or 
from intercurrent attacks of diseases which the weakened bodies are 
unable to resist. Of dysentery and much of the. diarrhea, impure 

2 The field latrine described in Jie text has fulfilled all that was expected 
of it, but since this chapter was written it has been largely superseded by the 
"McCall" incinerator, which received a thorough test at the camp of U. S. 
troops at the Jamestown Exposition. This device is a privy and incinerator 
combined. The fecal matter and urine are totally consumed by fire on the 
spot where thev have been deposited, necessitating no handling and but little 
daily labor. The apparatus is in two sections, one of which is in use as a 
privy while the other acts as an incinerator. The process of incineration is 
achieved without any noxious gases being given off. 



2S0 TEXT-BOOK OF HYGIENE. 

water is the principal and possibly the only cause, and in the Philip- 
pine Islands the one sanitary rule exceeding all others in impor- 
tance, and most insisted upon, is the purification, by boiling or distil- 
lation, of all drinking water furnished to the troops. 

It is practically impossible to prevent individual soldiers absent 
from camp or post, or during the march, from slaking their thirst 
at the nearest source, and, therefore, dysentery still claims its quota 
of victims annually. When to impure water are added bad food, un- 
sanitary surroundings, and reduced vitality, a form of acute dysentery 
may, assuming epidemic proportions, sweep through the camps with 
the virulence of cholera. This variety is not amebic, but is due to 
the Bacillus dysenteric of Shiga and sometimes possibly to other 
bacterial organisms. In civil life it occurs in overcrowded prisons 
and asylums, causing great mortality. A very important feature in 
the prevention of dysentery and the more serious forms of diarrhea 
among troops is prompt attention to the treatment of every slight di- 
gestive trouble, both by proper diet and medicines, for it often happens 
that an attack of acute intestinal indigestion, with simple diarrhea, 
is the starting-point for chronic diarrhea or amebic dysentery. 
The use of a woolen abdominal band when sleeping in the field is 
to be recommended. In the intense heat of the tropics there is no 
need to undergo the discomfort of wearing the band in the daytime, 
but at night the abdomen may easily become chilled, and the flannel 
binder is both comfortable and useful as a preventive measure. 

Malarial Fevers. — Next to intestinal diseases, malarial fevers and 
the resulting cachexia are accountable for the largest percentage of 
sickness in the United States army. Troops serving in the tropics 
suffer greatly from malaria, and when a command is once thoroughly 
poisoned with the malignant form of the disease it is practically 
destroyed, as far as its usefulness in war is concerned. 

In the Spanish-American war the Fifth Corps, nearly all regu- 
lars and the flower of the army, was, as a result of the operations 
in front of Santigo de Cuba, so affected with pernicious malaria that 
nearly all officers and enlisted men returned to the United States 
complete physical wrecks, necessitating either long furloughs or dis- 
charges for disability. 

The discovery of recent years, that malarial fevers are caused 
by several varieties of animal parasites in the blood and are con- 
veyed from man to man by the bite of certain infected mosquitoes 
of the family Anopheles, has led to methods of prevention founded 
upon positive knowledge, instead of the former vague ideas of infec- 



CAMP DISEASES. 281 

tion as due to noxious emanations from swamps, exposure to the 
night air, etc. 

In countries where malaria is prevalent, troops must be protected 
as far as practicable from the attacks of mosquitoes, by the use of 
screens and netting. Swampy and low-lying camps are avoided when 
possible, not on account of any toxic properties in marsh air, but on 
account of the well-known prevalence of mosquitoes in such places. 
In tropical countries inhabited by more or less uncivilized races, a 
safe distance should always be allowed between the camp and the 
native village. The inhabitants are sure to be more or less infected 
with a chronic form of malaria. They have, it is true, acquired a 
certain tolerance of the disease, and as they are not usually very sensi- 
tive to the annoyance of bites of insects, they never use screens. 

The mosquitoes infesting their huts are exceedingly apt to harbor 
•the malarial parasites, and a single night's camp made in a native 
village by a party of white men, unprotected by mosquito-bars, is 
often followed by an outbreak of fever. It is generally thought that 
a half mile is a safe distance to allow between the village and the 
camp. At military posts, cantonments, or permanent camps, a general 
war of extermination should also be waged against the insects. As 
the eggs of mosquitoes are deposited in standing water and the larvae 
live therein, all swamps, ponds, and puddles should be drained, or, 
when this is impracticable, the surface of the water should be kept 
covered with a thin film of petroleum, renewed about every two 
weeks. Wells, cisterns, and receptacles for drinking-water must be 
covered with wire screens. The fertility of the female mosquito 
is so great that thousands of the insects may be developed in cast-off 
tin cans, broken pots and bottles, which have collected rain-water 
and which are so universally found on badly-kept premises. Such 
rubbish must, therefore, not be permitted. 

Malaria can undoubtedly be banished from a community when 
each householder is held responsible for the maintenance of conditions 
unfavorable to the growth of mosquitoes on his premises. 

Sometimes, as in many places in the Philippines, mosquito- 
destruction on a large scale is entirely impracticable, the submerged 
rice-fields and thick jungles presenting too many breeding places for 
the insects. For instance, in palm-trees, at the junction of each 
great leaf with the stem there is a hollow space generally containing 
several quarts of water, each of which spaces may be the breeding- 
place of myriads of mosquitoes. Under such conditions, of course, 



282 TEXT-BOOK OF HYGIENE, 

preventive measures must largely consist in protection of the indi- 
vidual, rather than in insect-destruction. Malarial fevers are dimin- 
ishing rapidly in the United States army as a result of our present 
clear understanding of cause and effect. 

Yellow Fever. — The demonstration of the fact that yellow fever 
is also transmitted by mosquitoes, of the family Stegomyia, has taken 
it from the list of diseases which are to be much feared by armies in 
the future. 

The as yet unknown infective agent is in the blood of patients 
only during the first three days of the attack, and a mosquito ingest- 
ing the blood of a patient during this time does not transmit the 
disease until about twelve days have elapsed. Yellow fever has never 
been much of a camp disease, but troops occupying cities on the sea- 
coast in countries where it prevails have sometimes suffered terribly. 

The disease has been entirely eliminated in Cuba by screening the 
patients during their short infective period, and by destroying the 
mosquitoes in the infected house and those near by. There is hardly a 
doubt but that a little concerted effort on the same lines in the few 
places where yellow fever now exists will cause the complete extinc- 
tion of this disease in its endemic centers. 

Typhoid Fever. — This is always a serious and unfortunately a 
most common disease of camps. Pollution of the drinking-water sup- 
ply by the excreta of typhoid patients is usually assigned as the cause. 
While epidemics occurring in villages and cities are perhaps generally 
with reason traced to an impure water-supply, it is very likely that the 
typhoid fever of camps is transmitted from man to man in a much 
more direct way. During the Spanish-American war, the camps of 
volunteer soldiers in the United States were swept by this disease, 
although in many instances the water-supply was beyond suspicion 
of contamination. It being taken for granted as a fact that several 
hundred men can hardly be collected into a camp, anywhere in the 
United States, without at least one case of typhoid fever existing 
among them on arrival, the conditions of camp life will account for 
the spread of the disease. Unless the faecal discharges of all men 
are at once disinfected or removed, flies may carry infection from 
excrement in the sinks to food in the kitchens. Soil-pollution in 
and around tents from unrecognized cases of typhoid fever, and con- 
tamination by the sick of clothing, towels, utensils, etc., may in many 
different ways transmit the germ of the disease to other soldiers. The 
board of medical officers who studied the typhoid fever in the volun- 
teer camps of 1898 traced, in many companies and regiments, the 
gradual progress of the disease from tent to tent, and from man to 



CAMP DISEASES. 283 

man. Preventive measures against typhoid fever in camps should 
then include not only furnishing the troops with pure water, but 
also the immediate destruction or disinfection of all excreta, rigid 
protection of the soil from contamination, and careful personal 
hygiene. 

Cholera. — The precautions against typhoid fever apply also to 
Asiatic cholera. During the recent severe epidemic in the Philippine 
Islands, some garrisons were entirely free from cholera, although na- 
tives were dying by hundreds in the immediate neighborhood. It is 
hardly too much to say that nearly every case of cholera among the 
troops could be traced to a violation of the hygienic ru'es prepared 
for the soldier's guidance. Sterilization of drinking-water and the 
avoidance of native food and beverages, especially fruits and green 
vegetables eaten uncooked, were the leading measures taken. 

Phthisis. — Phthisis is now a rare disease in armies, as cases are 
promptly removed from barracks as soon as recognized, and in the 
United States army are sent to a special hospital at Fort Bayard, 
New Mexico. Opportunities for infecting others are thus avoided, and 
the patients given an excellent chance for recovery by suitable open- 
air treatment in a good climate. 

Typhus fever and scurvy have not for years figured in the list of 
camp diseases. In the light of modern hygienic knowledge it is not 
likely that they will again exist to any extent. 

Venereal Diseases. — The most discouraging feature of the sick 
report of armies is the great prevalence of venereal disease. Espe- 
cially in service when troops come into contact with a savage or half- 
civilized race is the large ratio of non-effectiveness from this cause 
particularly noticeable. In places under martial law, regulation of 
prostitution, with frequent inspection of the women, periodical ex- 
mination of the soldiers, and prompt segregation of all infected per- 
sons, will reduce venereal disease to very low limits. In times of 
peace, and under civil law, regulation of prostitution does not carry 
out all the claims of its advocates. It never reaches clandestine vice, 
and may even have a tendency to encourage it. Public opinion among 
English-speaking people is so entirely antagonistic to the regulation 
and licensing of prostitution, that it is quite hopeless to advocate it, 
even were it proved to be much more effective than the experience 
of foreign nations seems to indicate. 

Frequent inspections of the soldiers and prompt treatment in 
hospital, together with suitable instructions to recruits as to the 
dangers of venereal disease, are never to be neglected, although it 
must be confessed these are sadly inadequate means of prevention. 



QUESTIONS TO CHAPTER X. 

MILITARY AND CAMP HYGIENE. 

What subjects may be considered under this head? Why should an army 
be composed of sound and healthy individuals? Who should be excluded from 
an army or body of troops? What is the lowest age at which recruits should 
be enlisted? What the highest age? What should be the minimum measure- 
ments of the recruit? Who should make the physical examination of the 
latter? 

What can be said for the present army ration of the United States? 
What besides insufficient quantity and variety of food may cause digestive 
disturbances and innutrition in camp? 

What part of the United States soldier's clothing at present is most 
apt to cause physical discomfort? What change might be made to advantage 
in the manner of carrying the extra clothing? How is it now carried? 

What usually constitutes the dwelling of the soldier? What is a mili- 
tary barrack, and what is its general plan? What is to be said about the 
location of barrack lavatories, kitchens, and dining-rooms, sinks, and latrines? 
On what kind of soil should barracks be located? 

What sort of tents are used in the army? What are the advantages 
of the simple shelter tent? What may take the place of tents in winter? 
What is of the first importance in all camps, and what is necessary to secure 
this? 

In actual war what relation do the deaths from disease bear to those 
from injuries received in battle? What are the most fatal diseases of camp 
life? W T hat are the causes leading to this fact? What other class of diseases 
is especially apt to be frequent among soldiers? What effect has the mala- 
rial poison on those sick with other diseases? What would lessen the preva- 
lence of malarial fevers in camp-life? How may typhoid fever be propagated 
in camps and garrisons ? What respiratory diseases are common in camps, 
and to what are they due? What two diseases, formerly common in camp- 
life, are now rare? What contagious diseases are especially associated with 
the soldier? By what means may their spread be restricted? 



(284) 



CHAPTER XI. 

MARINE HYGIENE. 

Marine Hygiene may be briefly defined as being a specially de- 
veloped branch of General Hygiene. While the ultimate aims of both 
are identical, marine hygiene differs from land hygiene in that it 
presents for our study and investigation a series of peculiar environ- 
mental conditions, under the influences of which the individual 
members or communities of the sea-faring class are obliged to live 
and which are quite distinct from those which would surround the 
same individuals or communities if they were living on land. The 
marine sanitarian, therefore, stands between the sea-faring man on 
the one hand, and his peculiar and quite artificial environments on 
the other, endeavoring to maintain and promote the health, comfort, 
and happiness of the former by preventing or modifying, as far as 
it may be within his knowledge and power, the injurious influences of 
the latter. 

In the United States and in several of the European monarchies 
a distinction is made between marine and naval hygiene. This dis- 
tinction always appeared to be more apparent than real, until, within 
recent years, the modern battleship and cruiser were evolved and ap- 
peared on the scene. Since then there can no longer be any doubt 
about the fact that there is indeed a wide difference between the influ- 
ences upon human life of the conditions prevailing on these ships as 
contrasted with those existing on merchant ships. This difference is 
indeed so great that it deserves the special attention and study of the 
hygienist, and will continue to receive them in the future. Within 
the limited space of this article only those conditions will be dis- 
cussed that prevail on both classes of ships alike. 

HISTORICAL. 

The seaman, as regards his original composition, his character 
and instincts, as well as other human traits, may safely be said to have 
differed at no time from any other individual average member of the 
human family. The descriptions with regard to his life and character 
that we read about in history are indicative more of what can become 
of any normally constituted human being under the educational influ- 

(285) 



286 TEXT-BOOK OF HYGIENE. 

ences either of a life of romance and adventure, or of degraded condi- 
tions and inhuman treatment, or both these combined, than they are of 
any more essential difference in the original make-up of the man. 
He is, in other words, like any other man, more or less the result of 
the life he leads. 

In former times, when away on long voyages in sailing ships, away 
for long periods of time from home and friends, the seaman was often 
at the mercy of inhuman and cruel masters, who exacted excessive 
work in return for insufficient food, scanty clothing, poor lodging, 
abuse, and neglect when sick or disabled. The history of those early 
days abundantly shows how little attention, especially, was paid to 
sanitary matters; in fact, how little was known with regard to such 
matters. No records of ships' sanitation were kept. Some of the 
earliest recorded accounts of the medical treatment directed against 
the diseases peculiar to ships we find in a book published in 1693 by 
a Dutch surgeon named Verbriigge, while Vrolingh adds a brief de- 
scription of the provisions that were supplied to the men at those 
times and of the scurvy that they suffered from. 

The more important works on marine hygiene, in the beginning 
of the last century, were those of Lind, Eouppe, Duhamel de Monceau, 
Poissonier-Deperrieres, Smollet, Blane, Clark, and Meunier. About 
the middle of the last century the works of Forget, Fonssagrives, Mac- 
donald, Wilson, Turner, and Gihon came into prominence, and towards 
the end of the nineteenth century the quite advanced works of Eich- 
ard et Bodet and of Dr. Arthur Plumert appeared. 1 

Instead of regular sanitary records, kept by medical officers, we 
will have to depend upon the fragmentary accounts in ships' logs, 
kept by masters of vessels, for the very earliest records we possess 
with regard to sanitary matters on ship-board. According to these, 
the ravages of disease, at times, must have been positively appalling. 
Thus, for example, Admiral Anson, in 1741, reports the loss, within 
a few weeks, of 200 men by scurvy alone out of a complement of 
600 men; he landed on Juan Fernandez with but 8 men able to do 
duty. Geary, in 1779, is said to have had at one time in his squadron 
2400 cases of scurvy; and Eodney, in 1780, once lost from 50 to 55 
men of the same disease weekly, out of a complement of men number- 
ing only 2000. 

Ships' fevers were of the more frequent occurrence according to 

1 Also the following works on Naval Hygiene: Nocht, "Schiffshygiene," 
Berlin, 1905; Belli, "Igiene Navale," Rome, 1905; Couteaud et Girard, 
"L'Hygiene dans la marine de guerre moderne," Paris, 1905; "Jan et Plante 
Hygiene navale," in Brouardel et Mosny's "Traite d'Hygiene," 1907. 



HISTORICAL. 287 

reports. Under this head were summed up what we would now 
distinguish as typhus, typhoid, malarial, and other fevers. Thus, 
Lind, among others, says of a French fleet of vessels which, in 1757, 
was on its way from Louisburg to Brest : "This fleet was engaged in 
transporting 1000 convalescents from the various hospital tents at 
Louisburg to Brest. After the sixth day out most every one of these* 
had died." Blane, while fleet-surgeon of 40 line-of-battle ships, with 
21,608 men, cruising in the West Indies between 1780-1783, reports 
the loss of 3200 men from disease and but 1148 men from the enemy's 
guns, and he attributes this enormous death-rate to bad quarters, over- 
crowding, insufficient ventilation, poor food, and bad drinking-water 
combined. Many of the men, especially those who were obliged to 
work below, actually died from suffocation. 

In the "Souvenirs d' un Admiral," Jurien de la Gravieres, the 
following note by Admiral Latouche was found: "The ships of his 
squadron arrived at the 'Station du Nord' in the following condi- 
tion : The Cornette, with a complement of 400 men, had thrown 37 
overboard and sent 122 to the hospital; the Necessaire, out of a com- 
plement of 80 men, had thrown 13 overboard and sent 21 to the 
hospital; the Theobald had thrown 136 into the sea and landed 129 
in the hospitals, arriving with only 35 men in all in port." 

It is said that the men on these ships were crowded together so 
closely that there was scarcely as much breathing space for them as is 
generally allowed a man in his coffin. There was no provision whatever 
made for ventilation, much less for lighting. The decks below were 
both foul and dark, so that the human breath was believed to be fatal. 
Often the berth-decks were used for live-stock for fresh meat, and 
most of the men and all the sick were usually kept on this deck. The 
men, as a rule, were provided with but one suit of clothes, and this was 
worn until it literally dropped off their bodies. The only means they 
had of washing their clothes was to tow them alongside the ship in the 
sea-water while under way. The hammocks, we are told, were never 
taken off their hooks, neither were they scrubbed or aired, and one 
hammock often had to serve for the berthing of two men ; and these 
conditions prevailed on some of the station-ships down to 1856. The 
care of their persons was left entirely to the men themselves, the 
officers deeming it beneath their dignity to bother themselves about 
such details. No drills of a systematic order were performed, and 
punishment for the slightest infraction against the prevailing and 
mostly cruel regulations was usually prompt and of the most brutal 
nature. 



288 TEXT-BOOK OF HYGIENE. 

In spite of the shining example of Captain Cook, who, during 
his three-years' cruise, between 1772-1775, lost but one man of his 
crew, through a wise application of the simplest laws of health and 
humane treatment of his men, his experiences and the lessons it 
should have left behind went almost entirely unheeded. This, more 
"than anything else, shows that nothing short of the strictest laws 
and regulations can ever be depended upon to improve the sanitary 
conditions of the seaman, his life and surroundings. To see that these 
are enforced and carried out is the duty of the ship's sanitarian. 

Finally, the following anecdote, which is recorded as a part 
of the history of those days, may be cited, as illustrating the indiffer- 
ence to sanitary matters of the then class of masters of vessels who 
held undisputed sway. The story is told of an English admiral 
who was asked to stop his ship for the purpose of picking up the 
second surgeon, who had just fallen overboard. The admiral posi- 
tively refused to pick the man up, saying that it was only the ques- 
tion of a useless man on board, anyway. 

MORBIDITY AND MORTALITY OCCURRING IN SEAFARING 

PEOPLE. 

Although it must, perhaps, be admitted that the encouraging 
results obtained in recent years with regard to a decrease in mor- 
bidity and mortality rates among seafaring people, and which we find 
repeatedly recorded in these days, are in great part directly traceable to 
the improvements made in ships' construction, yet it must, I think, be 
likewise granted that, were it not for the great advances that have 
been made, more or less simultaneously, in scientific hygiene, the 
above-mentioned favorable results could not have been attained. 
Experience, both past and present, has repeatedly shown that with- 
out constant vigilance shown in the administration of hygienic laws, 
without constant sanitary supervision of the men on board ships, we 
would repeat the sad experiences of the past, in less time than it would 
take to tell it, in spite of iron ships that are run by steam instead of 
sail. The fact that scurvy and other diseases did not come from the 
wood of which the old ships were built, was clearly shown during the 
three-years' cruise of Captain Cook (1772-75), and the other fact 
that these same diseases are ready to recur on board any of the modern 
iron ships when allowed to lapse under the same unsanitary condi- 
tions as used to prevail in the old wooden ships a hundred years 
ago, are likewise well established by the reports of scurvy and other 
filth-diseases, known to occur up to the present day. To the improve- 



MORBIDITY AND MORTALITY IN SEAFARING PEOPLE. 289 

merits made in ships' construction we must, therefore, add those made 
in experimental hygiene and sanitary supervision. 

Better food, better water, more suitable wearing apparel, more 
light below decks, and, above all, more and a better quality of air, 
these are the direct results of the work done by hygienists and which 
the seafaring people never again will do without on board their ships. 
But, notwithstanding these improvements in both ships' construc- 
tion and hygienic living, there is still enough left to show that the 
life of the seaman, with regard to his home, his clothing, his food, the 
climatic influences to which he is exposed, his social comforts and 
enjoyments, are different from those of the rest of mankind. All 
these more or less abnormal conditions of life must still lead to cer- 
tain diseases other than filth-diseases, that will ever be peculiar to 
the seafaring class and the causes of which we must find out and try 
to eliminate. 

The lines along which we must proceed with our work will be- 
come clear to us from a study of the morbidity and mortality rates. 
These statistics will give us the first needed information. They will 
show us not only the nature, but also the extent, of the inroads which 
disease is making into the seafaring population, as well as the influ- 
ence which sanitary regulations have had from time to time upon their 
course. Notwithstanding the fact that Captain Cook, during his 
long cruise of three years, lost but one man from his crew, by wisely 
following out the laws of hygienic living on board his ship, his bril- 
liant example did not produce the widespread influence that it should, 
and was, apparently, only reluctantly followed. Among the auto- 
cratic masters of the seas of those times, precepts were without influ- 
ence; regulations of the strictest order alone produced any effect. 

According to Blane, the annual mortality in the English fleet 
in 1780 was 12.5 per cent.; in 1811 it had gone down to 4 per cent., 
and, during the period from 1830-64, it had dwindled down to 1.3 
per cent. This astounding diminution of the mortality rate of the 
English fleet is directly traced to a sanitary regulation which was 
issued by the Admiralty in 1791, revised and improved in 1797. 
This means an immense saving of human lives. 

Very valuable statistical tables have been worked out for us by 
Friedel, quoted by Kulenkampf. According to these authors, the 
morbidity and mortality of the English fleet, during the years 1830 
to 1864, were as follows: The mean annual strength of the fleet, 
calculated for the entire period of 34 years, was 35.269 men, among 
whom occurred, on the average, 121.2 per cent, cases of sickness; 2.69 

19 



290 



TEXT-BOOK OF HYGIENE. 



per cent, of which resulted in being invalided from the service and 
1.33 per cent. died. The influence upon morbidity and mortality of 
the different stations is well shown in the following table: — 



Table XXXIV. 



Stations. 


Number of 
Sick. 


Died. 


Daily Number 
of Sick. 


1. East Indies and China 


178.8% 

158.0% 

142.2% 

82.3% 

89.3% 


3.13% 
3.39% 

2.0% 

0.74% 
0.45% 


8.88% 
6.58% 
5.83% 


2. West Africa 


3. "West Indies and America 


4. Mail Service 


5. Home Stations 


4 8% 
4.38% 


6. Australia 



The relative percentage distribution among the more important 
diseases may be seen in table XXXV: — 



Table XXXV. 



Diseases. 


Per Cent, 
of Mean 
Strength. 


Diseases. 


Per Cent, 
of Mean 

Strength. 


Phlegmonous inflammations . 
Catarrhs 


23.3 

19.3 

10.9 

10.3 

7.8 

1.8 

0.12 


Variola 


0.15 


Erysipelas 


0.47 


Fevers (typhoid and malarial) 
Diarrheas 


Tuberculosis 


06 


Pneumonia and pleuritis . . . 
Delirium potator 


1.7 


Rheumatism 


0.28 


Dysentery 


Scurvy 


0.1 


Cholera 











In order to show the progress in sanitation made since that time, 
it will perhaps suffice to quote some figures from the more recent 
report of the Surgeon General of the United States Navy on the 
present state of the 

Health of the Navy and Marine Corps of the United States: — 
During the year 1902, the average strength of the active list of the 
Xavy was 31,240. The total number of admissions to the sick-list, for 
all causes, during the year 1902, was 22,645, or 76.8 per cent. There 
were 18,882 admissions for disease and 3,763 for injuries. The daily 
average of patients was 3.5 per cent, of mean strength. The total 
number of sick days was 374,466, or an average of 12.05 sick days for 
each man in the Xavy and Marine Corps, with an average duration of 
16.53 days' treatment for each case. 






MORBIDITY AND MORTALITY IN SEAFARING PEOPLE. 291 
Table XXXVI. 



Classification of Diseases 



Class I. 
Parasites and parasitic dis- 



Class II. 

General infectious diseases 

(nonvenereal) 

Class III. 
Constitutional disorders of nu- 
trition 

Class IV. 
Diseases of the nervous sys- 
tem 

Class V. 
Diseases of the visual appa- 
ratus 

Class VI. 
Diseases of the auditory appa- 
ratus 

Class VII. 
Diseases of the olfactory ap- 
paratus 

Class VIII. 
Diseases of the nutritive ap- 
paratus : 
Subsidiary class 1— 
Diseases of the digestive 

apparatus 

Subsidiary class 2— 
Diseases of the circula- 
tory apparatus 

Subsidiary class 3— 
Diseases of the respira- 
tory apparatus 



I 62 



Class IX. 
Diseases of the motory appa- 
ratus 



Class X. 
Diseases of the cutaneous ap- 
paratus 

Class XI. 
Venereal diseases and diseases 
of the genito-urinary appa- 
ratus 

Class XII. 
Cysts and new growths 

Class XIII. 
Injuries 

Class XIV. 
Extraneous bodies 

Class XV. 
Poisons 

Class XVI. 

Feigned diseases 

Total 



25 



312 



270 

2,769 

46 

1,039 

254 

164 

47 

2,664 

219 

1,039 

461 

1,348 

2,522 

43 

2,364 

12 

339 

4 



371 



17 



12) 



33 



12 



Invalided 



127 



2.433 



26 



914 



184 



108 



143 

40 
51 

56 



294 
3 



2,466 
134 
913 

403 

1,297 

2,043 
31 

2,120 

12 

329 



159 



672 



SI 



210 



82 



58 



15,674 1,373 13, 



287 
109 
196 

102 

114 

735 
15 

216 



16 



41 



3,061 



«3 

. a 

Is 

© *" 



196 



o 
~.2 



64 



2 J 21 



33 



60 



25 



35 



84 



718 
21,345 

566 
7,288 
2,447 

939 

134 

12,453 
3,004 
7,009 

3,635 

11,823 

26,261 

389 

21,612 

47 

1,378 

20 



65 407 I 121.068 



291 



TEXT-BOOK OF HYGIENE. 

Chart I. 



Causes of Death. 


Re/ation by Scale. 


N9 of 
Deaths. 


Drowning. 




27 


Typhoid Fever. 




15 
14 


Wounds. 




14 


Pulmonary Tubercu/osis. 




13 


Starvation 




12 


Bright's D/sease 




9 


Fracture 




9 


Va/vu ia r Heart Disease. 




8 


Alcoholism 




9 


Cholera . 




6 


Poisons. 




6 


Bronchitis, Chronic. 




4 


Dysentery, Acute. 




4 


Remittent Fever. 




4 


Appendicitis. 




3 


Endocarditis. 




3 


Smallpox. 




3 


Burns. 




2 


Cancer. 




2 


Cholera Morbus- 




2 


Concussion. 




2 


Contusion 




2 


Miliary Tuberculosis. 




2 


Diphtheria. 




2 


Yellow Fever? 




2 1 


Haemorrhage (Stomach) 




2 


Intestinal Obstruction. 




2 


Peritonitis. 




2 


Abscess of Liver. 




2 


Abscess. 






Angina Pectoris. 






Apoplexy. 






Asthma. 






Intestinal Catarrh. 






Dilation of Heart. 






Dengue fever. 






Diabetes. 






Dysentery, Chronic. 






Heart failure, Simple . 






Intermittent fever. 






Thermic fever. 






G astro - Enteritis. 






Meningitis. 






Myocarditis. 






CEdema ofLunfs 






Middle Ear Disease. 






Paralysis. 






Pleurisy- 






Pyaemia 






Septicaemia- 






Tuberculosis. 


_ 




Ulcer of Stomach. 






Rupture of Abdominal Organs 






Paralytic Dementis. 










MORBIDITY AND MORTALITY IN SEAFARING PEOPLE. 293 

Chart II. 




294 



TEXT-BOOK OF HYGIENE. 



The number of persons invalided from the service (including 
retirements of officers for disabilities and transfers to hospitals for 
the insane) was 1,144, or about 3.8 per cent, of mean strength. Two 
hundred and eleven deaths occurred during the year, or 0.41 per cent. 
for disease and 0.26 per cent, for injury. Among the causes for ad- 
mission to the sick-list, malarial diseases stand first with 1,408 admis- 
sions, wounds ranking next with 942 admissions, while epidemic 
catarrh, which has headed the list for the last three years, falls to 
third place, with 877 admissions. Dengue fever adds 531 admis- 
sions. Eheumatic and diarrheal affections rank next in preva- 
lence, with 799 and 783 admissions respectively. The number of 
admissions for mumps and measles was almost twice as great as in 
1901. The admissions for the epidemic diseases are: mumps, 330; 
measles, 245; diphtheria, 65; rubella, 48; small-pox, 23. Venereal 
diseases were as follows: Gonorrhea, 771; syphilis, 606; chancroid. 
284; alcoholism, 248. 

The total admissions for injuries of various character were 
2,940, being divided among wounds, 952; contusions, 706; sprains, 
612; fractures, 242; hernias, 175; burns, 171; luxations, 65; 
drowning, 27. 

Table XXXVI shows at a glance the numerical distribution of the 
cases among the sixteen classes into which, for convenience sake and 
statistical reasons, the diseases have been divided, while the two ad- 
joining charts will give a better idea (1) of the more prominent 
causes of death and (2) the prevalence in the Navy of the more spe- 
cial diseases and injuries. 

An example showing the enormous amount of work in marine 
sanitation done in various ports of the world, especially in the port 
of Hamburg under Dr. Nocht, of the detailed records that are kept 
and of the excellent and valuable statistical tables that are from 
time to time given to the medical world, the following will bear 
ample testimony: During the last seven or eight years there were 
under sanitary control : — 



I. In Cuxhaven: 



Table XXXVII. 



1896 


1897 


1898 


1899 


1900 


1901 


1902 


78 
Disinfected were . . 


116 
105 


148 
97 


229 
130 


579 
172 


665 
126 


846 ships. 
116 ships. 



MORBIDITY AND MORTALITY IN SEAFARING PEOPLE. 295 
II. In Hamburg: 

Table XXXVIII. 



1895 


1896 


1897 


1898 


1899 


1900 


1901 


1902 


19,359 


16,375 


15,458 


13,218 


14,099 


14,430 


17,708 


19,302 ships 



During these examinations it was noted that the following num- 
bers of cases of sickness had occurred on board these vessels on the 
trip preceding their arrival in the port of Hamburg, namely: — 

Table XXXIX. 





1895 


1896 


1897 


1898 


Internal 

External 

Venereal . . : 


2,763 (143) 
2,038 

294 

431 


3,923 (144) 
1,867 
1,599 
357 


3,197 (122) 
2,355 

417 

425 


7,624 (105) 
2.379 
4,939 
306 




1899 


1900 


1901 


1902 


Internal .... 
External .... 
Venereal .... 


9,805 (173) 
3,554 
5,932 
319 


10,789 

4,818 

5,631 

340 


14,365 
6,087 
7,221 
1,057 


15,163 cases 
5,513 " 
8,260 " 
1,390 " 



Brackets ( ) mean deaths. 

Their distribution among the most important diseases was as 
follows : — 

Table XL. 



1895 



1896 



1897 



1900 



1901 



1902 



Cholera 

Yellow fever 

Variola 

Diphtheria 

Malaria 

Typhoid 

Dysentery 

Consumption 

Scurvy 

Beri-beri 

Heat and heat-stroke. 
Heart disease 



5 (4) 
40(24) 

6 (2) 



635 (5) 
7 (2) 

10 

25(10) 

37 (2) 
5 (3) 

83 (9) 



1 

48(26) 

3 

1 
961(12) 
10 (3) 
33 (5) 

9 (3) 
76(11) 
17 (5) 
54(10) 



2 (2) 
6 (5) 
1 

1 
807(20) 

3 (2) 
23 )4) 
20 (2: 
12 (1) 
20 (7) 
27 (7) 



2 (2) 



1 

584 (3) 

7 (1) 

12 (1) 

11 (3) 
1 

12 (4) 
69(15) 
15 (3) 



1 

3 

1 

547(27) 

13 (2) 
8 (5) 

39(19) 
27 (2) 
23 (8) 



10 (8) 

1 

404(21) 
6 (1) 

10 (1) 
13 (8) 
12 

11 (8) 
86 (19) 
23 (7) 



2 

1 

4 
591(14) 
33 (1) 
25 (2) 
20 (6) 
35 (4) 
14 (8) 
63 (3) 
28 (5) 



14 (7) 
5 (4) 
3 

4 n) 

593 (2 <) 
17 (6) 
22 

11 (2) 
22 
45 (3) 



42^21) 



296 



TEXT-BOOK OF HYGIENE. 



During the last three years the number of cases of sickness occur- 
ring among passengers on 138 steamers that came into the port of 
Hamburg was 3450. Two hundred and thirty-nine of these ended 
fatally and 1380 were infectious diseases: measles, scarlatina, rube- 
ola, diphtheria, variola, etc. 

On one ship two cases of plague occurred. Eelatively numerous 
are said to be abortions and uterine haemorrhages, caused by sea- 
sickness. On board these same steamers 4802 seamen received medical 
treatment; among these 389 cases were infectious diseases, with 25 
deaths. The annual average number of sick seamen, derived from the 
records of the last eight years, as arriving in the port of Hamburg, 
is 2343, being distributed, likewise by annual averages, as follows: 
Internal diseases, 1047; external diseases, 795; venereal diseases, 
553. According to the calculations of Dr. Nocht, every physician 
employed on these steamers, during a forty-days' trip, had under 
treatment, on the average, ten serious cases of sickness. 

Casualties and Disabilities Due to Shipwreck. — The total loss in 
vessels caused by shipwreck, during a period of ten years, amounted 
on an average, (1) in the English merchant marine, to 2.43 per cent.; 
(2) in the French merchant marine, to 2.36 per cent.; and (3) in the 
German merchant marine, to 1.86 per cent. In the German service 
the total loss of human life due to these accidents was 0.53 per cent, 
of the crews. The Seaman's Insurance Bureau at Hamburg, in its 
annual report for 1893, gives the following valuable information with 
regard to these casualties: — 

Table XLI. 

Accidents Reported. 



Vessels 


Number of Men 


Number of 
Accidents 


Accidents 
per 1000 


Deaths per 1000 


Steamers 


24,636 

15,595 

1,277 


1,423 

636 

5 


57.76 

40.79 

3.92 


6.09 


Sailing vessels 

Employed 


21.74 







The Seaman's Insurance Bureau, in 1892, had on its books 
43,023 insured seamen and paid insurance to 1668 persons. Out of 
this number the disability incurred by 1571 persons proved to be 
but temporary and lasted less than 13 weeks; of the remaining 97, 
8 remained permanently disabled and the rest died. The total num- 
ber of registered sea-going vessels at the time was 2742 sailing ships, 
manned by 17,522 men, and 986 steamers, manned by 24,113 men. 



THE DRAINAGE OF SHIPS. 
Table XLII. 

Accidents Occurred as follows : 



297 



Year 


Number of 
Ships 


Number of 
Men 


Died 


Number of 
Passengers 


Died 


1889 
1890 
1891 


116 

92 

116 


1,015 

937 

1205 


208 
169 
177 


331 
174 
160 


274 

7 

30 



THE DRAINAGE OF SHIPS. 

We say of a city or town that it is drained either according to the 
combined or the separate system, in accordance as to whether all the 
offal is discharged combinedly through one set of pipes, or whether 
the rain and the washwater are made to flow through a pipe system 
separate from this. In keeping with this nomenclature we may say 
of a ship that it is drained in accordance with the principles of the 
separate system. For, although the methods of ships' drainage are 
perhaps more complicated than are those of cities and towns, they, 
naturally, may be divided into two principal methods : — 

1. The sea-water coming on board, the rain-water, the wash- 
water, the water circulating in the pipes of the flushing system, after 
passing through the various closets, the refuse from the kitchen, the 
ashes from the furnaces, are all made to pass overboard in the most 
direct ways. 

2. The refuse matters from the engine- and boiler- rooms, those 
from the various magazines and storerooms, the rain-, sea-, and wash- 
water from the lower decks, all these find their way into the lowest and 
most dependent compartments of the ship by gravity, finally collect- 
ing in what is known as the bilge-room. Thence the combined mix- 
ture, known as bilge-water, is pumped overboard by powerful station- 
ary suction-pumps. These suction-pumps generally terminate, with 
their open mouths looking downward, within a few inches from the 
bottom of the ship, being protected by wire gauze baskets to keep out 
solid matters. Their arrangement, while simple enough in a wooden 
ship, or even an iron merchant-ship, in a fully equipped modern 
battleship, the number of pipes of all sizes, their many valves and 
cross connections, are positively bewildering, and none but an expert 
can be entrusted with the laying out of a complete system in perfect 
and absolutely reliable working order. The drains are usually di- 
vided into main, auxiliary, and secondary drains, according to size. 
The large fifteen-inch main drain on a big battleship is only used to 






298 TEXT-BOOK OF HYGIENE. 

pump out very largo quantities of water in case the ship's bottom 
is punctured; while the auxiliary drains are employed in pumping 
out the accumulated bilge-water at regular intervals, and the second- 
ary drains connect with the smaller local accumulations. 

The pumping and drainage system below the protective or water- 
tight deck of a modern man-of-war may be said to be divided into 
three parts, viz : emergency, surface, and double-bottom drainage. 
Each part is provided with separate and distinct piping, working 
independently, if desired, yet so interconnected with the others by 
means of valves that they all may be made to work in unison. 

The main drain (see Fig. 33) may be styled the emergency 
part, and consists of a pipe, ranging in size from 5y 2 inches to 15^2 
inches, according to the size and type of the ship, and extending from 
the after part of the forward fire-room to the after part of the after 
engine-room; its flanges are made water-tight on every main water- 
tight bulkhead it is made to pierce. The main drain generally runs 
on one, usually that side of the vessel where the center line longitu- 
dinal watertight bulkhead is fitted, throughout the length of the 

boiler compartments, branching I j 1 shape just aft of the for- 
ward bulkhead of the engine space, a branch being carried into each 
engine-room and connected to the main centrifugal pump in each of 
these compartments. In each compartment traversed by the main 
drain is a suction valve, the full diameter of the pipe, operated at 
the valve and also by means of a rod from the deck above. Branches 
from this main drain are led through the center-line bulkhead and 
fitted with valves at the end, so that all of the main machinery com- 
partments are connected directly to this large emergency drainage 
pipe. 

Each steam-pump throughout the machinery space, which in any 
manner is connected with drainage, has a suction connection with the 
main drain, so that one pump or all pumps may be made to work on 
this pipe whenever required to do so. The main drain is used only 
in case of an emergency, that is, when the water in any compartment 
is found to be rising above the floor-plates and cannot be controlled 
by the other drainage connections. Such an emergency would arise 
only on account of a vessel striking rocks or taking ground, thus 
injuring the inner bottom and causing a leak of great magnitude, or 
by a torpedo striking below the water line and injuring one or more 
watertight subdivisions. 




OUTSIOt PLATING 



".DOCKING KEELS 



Fig. 33. — Cross-section of Ship, Showing Arrangement of 
Drainage System. 



(299) 



300 TEXT-BOOK OF HYGIENE. 

By surface drainage is meant the drainage of all water that col- 
lects on top of the inner bottom in engine- and boiler- rooms, in store- 
rooms or other places throughout the whole length of the ship, not in 
double bottoms. Each watertight compartment throughout the length 
of the inner bottom has provided at its lowest part what is known 
as a bilge-well (see Fig. 33), that is, a rectangular, cup-shaped de- 
pression about 10 x 18 x 6 inches, worked into the inner bottom plat- 
ing. Into these bilge-wells the suction ends of all the suction pipes 
are placed, so as to provide the conditions for each compartment be- 
ing pumped as dry as possible. The principal pipe attending to sur- 
face drainage is called the "secondary drain" (see Fig. 33), to dis- 
tinguish it from the pipe called the "main drain." The secondary 
drain usually runs on the side of the ship opposite to the main drain, 
and extends from the forward end of the forward boiler-room to the 
after end of the after engine-room, connecting to a manifold (in other 
words, a series of valves cast in one chest) at each end and having 
branches leading to each bilge-well in every watertight compartment 
throughout the machinery space. 

Each steam-pump connected with the drainage system, except 
the main centrifugal circulating pumps, is provided with a suction 
to the secondary, and is so arranged that, by the manipulation of 
certain valves, any compartment may be pumped by any pump or by 
all pumps, if necessary. From the manifold, at each end of the 
machinery space, branch pipes extend to the several compartments 
forward and aft, so that the pumping of the several compartments 
forward and aft may be controlled from within the machinery space. 
The suction ends of all the branches within the machinery space are 
provided with Macomb strainers, and the suction ends outside of the 
machinery space are protected by perforated box-strainers, thus pro- 
tecting the piping as well as the pumps from becoming clogged by 
any extraneous matter. 

In addition to the secondary drain, the extensive functions of 
which may now be realized from the above description, a separate 
pipe, known as the independent "bilge suction" (see Fig. 33) is led 
from each steam-pump to the bilge-well of its own compartment, so 
that each compartment may, by its own pump, be kept dry without 
dirtying up the secondary drain. For pumping the crank-pit a 
small pump on the main shaft of the engine, known as the "shaft 
bilge-pump," is provided. This crank-pit, however, is also connected 
to the secondary drain and an independent suction, so that, in case the 



THE DRAINAGE OF SHIPS. 301 

shaft bilge-pump is out of order, the water in the crank-pit may still 
be taken care of. 

The double bottom is either flooded or pumped through a pipe 
known as the "double-bottom pumping or flooding main" (see Fig. 
33), which is a single pipe in boiler space and a single pipe in engine 
space, with a branch controlled by a valve leading into each water- 
tight compartment of the double bottom and with a connection direct 
to the sea and to one or two steam-pumps within the machinery space. 
The double bottoms throughout the machinery space are the only 
places provided with a flooding connection; while the double bot- 
toms forward and aft the machinery space have suction connections 
only, and are pumped by means of the secondary drain through the 
manifold in the forward boiler-room and the after engine-room. 

Summary. — From the foregoing brief description it will be seen 
that the main drain is an emergency drain, being used only to reduce 
large volumes of water; it is never brought into requisition for the 
purpose of reducing surface water. That the secondary drain, with 
its ramifications and auxiliaries, is employed to reduce all surface 
water usually collecting in the machinery space or such water as col- 
lects in holds or store-rooms, or for pumping out the forward or 
after tanks; finally, that the double bottom and flooding main looks 
after all water within the double bottoms. 

No suction pipes are led into the coal bunkers or magazines. 
Such water as collects under the floor-ceilings of the coal-bunkers 
is pumped out by means of a hose passed through the coal-bunker 
door. The magazines proper, without handling rooms, are pumped 
out after a flooding by means of a hose passed through a cap in the top 
of the magazine. 

In most of the wooden ships the bilge-room consists of a tri- 
angular-shaped space running along the entire length of the ship's 
bottom and inclosed between the bottom, the loose deck-planking, and 
the keelson (see Fig. 34). The numerous ribs of the ship divide this 
space transversely into a number of partitions, between which, how- 
ever, communications are established through borings, forming the 
so-called waterways (see Fig. 35). In iron ships, the ribs being fur- 
ther apart, these partitions are broader and more spacious, as well as 
deeper (Fig. 35). 

When double bottoms were introduced, and when these were 
used for the storage of iron tanks containing feed-water for the 
boilers, the bilge-spaces underwent a lateral displacement and came 
to be located between the inclined planes of the ship's sides and those 




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Fig. 37.— Showing Location of Bilge-space on Top of Double Bottom. 

20 (305) 



306 TEXT-BOOK OF HYGIENE. 

of the double bottoms, where they took the form of a shallow gutter 
(see Fig. 3(5). When, still later, the double bottoms were run up 
still higher on the ship's sides, these gutters disappeared and the 
bilge-spaces again were made to occupy the center line on top of the 
double bottoms (see Fig. 37). A further transverse division of the 
bilge-room occurred through the introduction of complete watertight 
bulkheads, running from side to side and from the bottom up to and 
through several decks, dividing these into complete and separate com- 
partments in a transverse direction and without any communication 
between them, except, perhaps, through watertight doors. 

Thus we see how the changes that have taken place from time to 
time in the methods of ships' construction have also materially af- 
fected the location of the bilge-spaces, and thus radically altered the 
composition and, consequently, the sanitary significance of the bilge 
itself. The old conception of bilge-water no longer holds good and 
needs a change. 

One of the principal sources of the bilge-water in wooden ships 
was the sea-water, which in all wooden ships leaked through the bot- 
toms. This water would accumulate in the most dependent portion 
of the ships' bottoms, where it would take up the offal from all sorts 
of cargo and provisions, the wash-water from the lower decks, the 
cadavers of small animals, dirt and dust from the sweepings, etc., 
etc. The whole would, in time, result in a thick, black, malodorous, 
fermenting fluid, filling the air with foul-smelling gases, splashing 
through the loose flooring laid over it, while the ship was under way, 
and soiling it and everything else in contact with it. 

On iron ships, the sea-water as the chief source of the bilge- 
water leaking through the ship's bottom is almost entirely done away 
with, for their bottoms allow no salt water to get through them. 
The only place through which salt water can still get into the bilge- 
room is the shaft-alley. The consequence is that, with ordinary care, 
it is possible to keep the bilge-room in these ships dry. Often the 
spaces between the timbers are filled with cement right up to the 
limber holes (see Fig. 36), so as to guide the bilge-flow from one 
partition into the other and to prevent any accumulation in any of 
them. 

Thus, then, we will have to admit that what was known as the 
bilge on board the old wooden ships can no longer be considered the 
same thing on board our more modern iron ships. But still, differ- 
ent though it be in composition, the bilge will and must continue to 
receive the most careful attention and scrutiny of the ship's sani- 



THE COMPOSITION OF THE BILGE. 



307 



tarian, as remaining a source of contamination of the ship's atmos- 
phere, whenever it is allowed to accumulate and to undergo decom- 
position inside of the ship. Both chemical and bacteriological ex- 
aminations of the bilge will always have to be done, whenever the 
health of the personnel of a ship becomes a matter of serious concern. 



THE COMPOSITION OF THE BILGE. 

Notwithstanding the fact that bilge-water had always been looked 
upon by all classes of seafaring people as the most dreadful disease- 
breeder and as the most universal source of atmospheric contamina- 
tion on board all classes of ships, no serious scientific attempt at 
analysis was made until 1885 (Belli), when Nicati and Rietsch pub- 
lished the results of their investigations on the viability of the cholera 
bacillus in bilge-water. The possibility of importing this bacillus into 
Europe in bilge-water had been thought of, but the results of the 
experiments proved negative. A year later, Koch and Gaffky made 
some experiments on the disinfection of bilges and came to the con- 
clusions that mercuric bichloride was the most efficient means for 
the disinfection of bilges and bilge-water. In 1891 Forster and 
Ringeling published the most thorough and painstaking experiments 
that had been made on the subject up to that time. The most im- 
portant fact brought out by their experiments and observations was 
that the composition of bilge-water varied within the widest limits, 
not only in different ships, but also in different parts of the same 
ship, as is best shown in one of their own tables: — 

Table XLIII. 

Variatioms in Composition of Bilgewater. 



Dry Residue 


Combustible 
Substances 


Oxygen Con- 
sumed 


Chlorine 


Sulphuric Acid 


Ammonia 


58-244.8 


0.1-165.2 


0.06-11.4 


1.6-86.3 


0.11-2.65 


0.002-0.91 



Interesting in this connection are the observations of Dr. Nocht, 
which were published in 1893 and which are shown in the next 
table : — 



308 



TEXT-BOOK OF HYGIENE. 
Table XLIV 

Shotting Composition of Bilge. 



Ship 


Where Formed 


General Properties 


Sail (wood) 

" (iron) 

Steamer (iron) 
i( a 

U < 


Cargo-room 
(i « 

Machine-room 

Cargo-room 

Machine-room 


Brown, tnrbid, muddy 
Black, turbid, very muddy 
Yellowish, clear, thick 
Clear, colorless 
Turbid, black, very muddy 
Opaque, colorless, no sediment 



Odor 


Reaction 


Chlorine per Litre 


Number of Germs per 
Cubic Centimeter 


Sweetish 


Neutral 


9,585 


325,000 


Stinking 


Slightly Alkaline 


12,780 


100,000 


No odor 


Strongly Alkaline 


49,500 


300 


No odor 


Neutral 


664 


15,000,000 


Foul 


Slightly Alkaline 


10,615 


3,000,000 


No odor 


Neutral 


5,573 


4,500 



Two years later Ringeling discovered two pathogenic anaerobes 
(septic vibrio and tetanus) in a portion of water taken from near the 
keel of a ship, and in 1896 Rocci, then surgeon in the Royal Italian 
Navy, studied the disinfectant value of milk of lime upon the most 
common bacteria found and isolated from bilge-water. The very latest 
and, at the same time, the most thorough and extensive examinations 
into the composition of bilge-water ever made are those published by 
Dr. Carlos M. Belli, of the Royal Italian Navy. These results are so 
important, especially as representing the facts as they exist on board 
men-of-war, that his tables have been in part reproduced. 

An examination of these tables shows that Belli employed the 
most up-to-date chemical, microscopical, and bacteriological methods 
in his work on bilge-water. Of quite particular interest are his inocu- 
lation experiments. He inoculated animals subcutaneously with 
samples of bilge-water amounting to 3 / 4 cubic centimeter for a dose, 
in order to ascertain whether they produced any possible pathogenic 
effect. In none of his many experiments was such an effect noted, 
although his animals were kept under observation for two months 
after being inoculated. He, moreover, tested the cultural properties 
of various types of bilge-water in both the natural state as well as 
after filtering it through Berkefield filters. As test-objects, 24-hour 
cultures of typhoid, cholera, icteroides, and staph} r lococcus pyog. aur. 
were used. Although the numerous and important details of this most 
extensive investigation on the composition of bilge-water must be 



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310 



TEXT-BOOK OF HYGIENE. 

Table XLVI. 

Bacteriological Examination of Bilge-water. { Belli. ) 



Bilge-type 


Ships 


Average 

Number of 

Bacteria 

per c.cm. 


Species Identified 


Engine- 
room 


Monzambano 

Calabria 

Dogali 

C. Alberto 


239,000 

2,141,000 

984,000 

307,000 


Many colonies of chromogenic saprophytes ; 

some colonies resembling bacillus coli. 
Few hyphomycetes, and of the schizomycetes 
those common in sea water. 
Very few schizomycetes ; chromogenic cocci 

and few bacilli, of which fluor liquefaciens 

are in greatest number ; few proteal. 
Numerous colonies of hyphomycetes ; of the 

schizomycetes, some colonies of cladothrix ; 

large numbers of chromogenic water coco 

and bacilli. 


Boiler- 
room 


Monzambano 
Calabria 
Dogali 
C. Alberto 


362,000 
1,016,000 
3,289,000 
1,000,000 


8parse number of fungi, many fluor liquefa- 
ciens. 

Mostly hyphomycetes and blastomycetes ; 
few speeies. 

Very large number of schizomycetes, common 
to engine-rooms. 

Sparse hyphomycetes; schizomycetes, common 
to engine-rooms. 


Provision- 
room 


Monzambano 

Calabria 

Dogali 


652,000 

333,000 

1,261,000 


Various colonies of proteal and potato-bacilli. 
Principally blastomycetes, less hyphomycetes. 
Mostly all blastomycetes; few hyphomycetes, 
some colonies of sarcina lutea. 



Table XLVII. 

Microscopical Examination of Bilge-water. (Belli.) 



Type of Bilge 


Ships 


Results 


Machine-room 


Monzambano 
Calabria 

Dogali 
C. Alberto 


Crystals of organic and inorganic salt, protozoa. 
Pretty large numbers of algae and protozoa, crys- 
tals, hemp-threads. 
Salt crystals, no living forms. 
Salt crystals, hemp-threads, no protistae. 


Boiler-room 


Monzambano 

Calabria 

Dogali 

C. Alberto 


Coal-dust. 

Coal-dust, no living forms. 

Coal-dust, few protozoa (ameboid and rhizopod 

forms. ) 
No living forms, sparse carbon particles and salt 

crystals. 


Provision-room 


Monzambano 

Calabria 

Dogali 


Mineral and vegetable dust, numerous rhizo- 
pods and flagellates. 

Salt crystals, vegetable fibres and grains, few 
protozoa. 

Vegetable fibres and hairs, salt crystals, no pro- 
tozoa. 



THE COMPOSITION OF THE BILGE. 31 1 

studied in the original monograph in order to be properly appreciated, 
it would seem unavoidable to give a brief summary of the results 
in this place. 

1. Bilge-water of the Engine-room Type. — To judge from the 
amount of chlorine which this water contained, it was concluded that 
the basis of it was salt-water mixed with a certain amount of sweet 
water derived either from rain-water or condensed water, added to 
which a variable amount of machine-oil was found. The relative 
proportions in the amounts of ammonia, nitrous acid, nitric acid, 
organic matters present; the absence, on the other hand, of sulphur- 
etted hydrogen, naturally led to the conclusion that the processes of 
decay in this type of water are extremely slight. This is, moreover, 
confirmed by the absence of bacteria, always present in decaying sub- 
stances. These waters possess no pathogenic properties. 

2. Bilge-water of the Boiler-room Type. — The chemical analysis 
of the waters belonging to this type shows that, in ships lying at an- 
chor, these waters are preponderatingly made up of sweet water, 
formed in all probability from the feed-water of the boilers and part 
of which is spilled in the process of filling. In ships under way it 
changes its character from a sweet to a salt water. Here, also, pro- 
cesses of decay were absent. 

3. Bilge-water of the "Cambuse" Type. — The chemical, micro- 
scopical, and bacteriological characters of this type were found to 
vary quite considerably. The sedimentary portion, underlie micro- 
scope, showed small grains, fibers, hairs from planks, many forms of 
crystals, algae, and protozoa. The most common type resembled sea- 
water mixed with various contents from barrels. Acetic fermenta- 
tion was frequently present, while other processes of decay were 
absent. 

4. Bilge-water of the Store-room Type. — This type of water is 
essentially a sweet water with which a small amount of salt water is 
mixed. It is probably for the most part rain-water. Processes of 
decay are here present constantly. 

It will be seen that, from the physical, chemical, and micro- 
scopical characters of these four different types of bilge-water, it is 
easy to distinguish one from the other; but even without taking 
these into account, it is still possible to distinguish the engine-room 
bilge by the oil with which it is mixed; that from the boiler-room by 
the coal-dust or soot which it contains ; that from the cambuse by the 
acetic acid; and that from the store-rooms by the foul odor of the 
decaying substances which it contains. 



312 TEXT-BOOK OF HYGIENE. 

From a hygienic point of view it is worthy of being emphasized 
that the different bilge-waters in battleships, especially those from 
the engine- and boiler- rooms, show either no evidence at all of decay 
going on in them, or that the evidence is present only to a very slight 
degree. This condition can only be the result of the better sanitary 
attention which these places receive on men-of-war, when contrasted 
with similar places on merchant ships. In the bilge-waters coming 
from beneath store-rooms, chemical examination, even here, shows 
evidence of advanced processes of decay in spite of the fact that the 
stores in question could not naturally be considered as very decay- 
able. One of the most interesting facts brought to light by the bac- 
teriological examination is this: that the engine- and boiler- room 
bilges of battleships contain either no proteaa at all or their numbers 
are very small, while the store-room bilges literally teem with them. 

The persistently negative result obtained from the inoculation 
of bilge-water into experimental animals would indicate that, at least 
under ordinary conditions, these waters are free from both pathogenic 
germs and poisons. This, of course, does not exclude the possibility 
that, under other conditions, they might become the carriers of 
pathogenic germs, although, as has been shown, this danger even then 
would not be of long duration, since experiments have shown that 
the vitality of pathogenic germs in these waters rarely endures beyond 
five days. It was also found that the dirtier such water was, the less 
the chances of the survival of disease-producing germs would be. 

Altogether, then, it would seem, from an analysis of the total 
results of these investigations, as if the dangers to the ships' per- 
sonnel from the bilge-waters on board battleships had been slightly 
exaggerated, or could not, at any rate, be at all compared to what 
they are on ships of the mercantile marine. Such a result, it must, 
however, be remembered, can only be due to the strict sanitary super- 
vision accorded the bilges on men-of-war generally. Frequent cleans- 
ing of the bilges, aided by regular timely disinfection, must, in the 
end, be depended upon for rendering all kinds of bilges absolutely free 
from danger to the health of the men. 



THE SHIP. 

1. Construction. — Desirable as it would seem, by way of an intro- 
duction into marine sanitation, to give a brief outline of ships' con- 
struction, space does not permit here to give more than the gross 
divisions of a typical vessel. Fortunately, the points regarding marine 



THE SHIP. 313 

architecture that it is absolutely necessary for the sanitarian to know 
are few, and need hardly extend beyond a knowledge of the materials 
of which a ship is built, its various divisions and compartments and 
the special uses to which these are put, in order to enable him to suc- 
cessfully trace the sources of mischief to human life produced thereby. 
The marine sanitarian need not be a constructor, any more than the 
public health officer need be an architect or an engineer. 

For the marine architect by profession, the problem of construct- 
ing a small gunboat varies immensely from that of a large battle- 
ship, while for the marine sanitarian most of the problems that come 
within his province remain, fundamentally at least, the same in both 
cases. Thus, every ship of no matter what type or description is more 
or less damp, dark between decks, and difficult to ventilate thoroughly, 
so that it may safely be taken for granted that dampness, darkness, 
and poor air are the three main and most constant factors entering 
into every problem of ships' sanitation. When we add to these ex- 
treme heat for all large steam vessels of modern construction, we have 
indeed all the four elements against the influences of which sani- 
tarians must direct their principal efforts. 

The difference between merchant ships and warships grows wider 
every year. Thus, for instance, in a modern Lloyd steamer there are 
at present five decks. Beginning from above downward we have, first, 
the sun-deck; next, the promenade deck; third, the upper deck; 
fourth, the main deck; and fifth, the 'tween-deck. Below the last 
deck and abaft the engine-room there is the shaft-alley, and in the 
corresponding situation forward of the boiler-room we have the coal- 
bunkers and the various store-rooms for provisions. On the berth- 
deck, from bow to stern, there are the bunks for the steerage passen- 
gers, and also on the main deck forward of the smoke-pipe. The 
crew lives on the forward part of the upper deck, under the fore- 
castle. The first cabins and the rooms for the officers are on the 
promenade and upper decks. 

The cubic space to be allowed per man is nowadays prescribed by 
law in every civilized country, and usually amounts to 100 cubic feet, 
with a minimum floor area of 9 feet. This is said, especially by 
English surgeons, to be too small an amount, but, while admitting the 
justice of the complaint, as Kulenkampf and Nocht have pointed out, 
part of the unhealthfulness of the quarters lies on the side of the 
interior arrangements of their living spaces, as well as in the insuffi- 
ciency of the available air-space. Nocht, in 1895, measuring 100 
ships, found the amount of air-space allowed per man to be 125 



314 TEXT-BOOK OF HYGIENE. 

cubic feet, that is, Bomewhat in excess of the minimum allowance re- 
quired by law. Nocht, also, is of the opinion that internal cleanli- 
ness and a more judicious arrangement of the interior of the living 
spaces would be productive of greater good than an increase in the 
cubic capacity alone would be. 

Very different and somewhat more complicated and difficult to 
understand than in a merchant steamer, are the various divisions and 
subdivisions of a modern first-class battleship. A large 16,000-ton 
battleship, complete in all its parts, in full motion and in action, 
approaches perhaps nearer to a colossal living organism than any other 
product of human ingenuity of recent date. 

To begin with, everything about such a vessel, that can be, is 
made of steel or iron, to resist not only the waves in the heaviest 
storms, but also the heaviest armor-piercing shot and shell. Fig. 
38 is intended to represent, schematically, the main divisions of 
one of the latest types of a first-class battleship. It will be noticed 
that the thickest line in the drawing, running fore and aft and in- 
clining slightly at either end, divides the entire ship into an upper 
and a lower half. This line indicates the position of what is known 
as the protective or armored deck. All the other decks are above 
the protective deck, and below it we find all the store-rooms, boiler- 
rooms, coal-bunkers, engine-rooms, steam-steering rooms, magazines, 
ammunition passages, and trimming tanks. 

The different decks, from above downwards and extending be- 
tween the two military masts are the bridge, upper deck, main deck, 
gun-deck, protective or berth deck; with a flying bridge, situated 
above the bridge around the forward military mast. The berth-deck 
proper is that part of the protective deck which is continued in an 
even plane forward and aft respectively from the protective deck, from 
the points at which the armored deck inclines downward for a short 
distance, forming an acute angle with the berth-deck. 

As a general rule, all the men's living quarters are on that por- 
tion of both the gun-deck and berth-deck which is forward of the 
after turrets, while the officers' quarters, with their mess-rooms, are 
on the same decks abaft the after turret. Immediately beneath that 
part of the armored deck included between the two military masts, 
are the engine-, fire-, and dynamo- rooms. Forward of the dynamo- 
room and abaft the engine-room respectively and between the pro- 
tective deck and the inner bottom, we have what are known as the 
upper and lower platforms, which carry stores and ammunition. 
Between the inner bottom and the outside plating there are the 




fPH=ft 







bo 



(315) 



316 TEXT-BOOK OF HYGIENE. 

double bottoms. All the points marked W.T. on the drawing con- 
cern watertight bulkheads. 

Fig. 33 represents a vertical cross-section from the same type 
of ship as the preceding, through the boiler-rooms; the decks shown 
in this figure are the same as those shown in Fig. 38. In the boiler- 
room, to the left of the reader, may be seen the terminal of one of 
the large ventilating shafts, of the usual form, ending a little below 
the plane of the deck above and quite a little above the heads of the 
men. The lid shown in the figure attached to its lower end is to be 
closed in case forced draft is desired. When this lid is closed, the 
air is driven by the adjoining fan in a direction at right angles to 
the long axis of the shaft, and thence down into the boiler-room 
toward the furnaces, where it is intended to increase the combustion 
of fuel and the production of steam. The pressure which this forced 
draft arrangement is able to produce is said to be equal to l^ ounces. 
On the right side of the sketch the ventilating terminal is shown to 
have a different arrangement. Here, the air is purposely shown to be 
carried down much further and, moreover, conducted to the sides of 
the room before being released from the main shaft. The figure 
was intended to show a flattened and perforated iron casing applied 
against the bulkhead through which the air was made to enter. This 
arrangement is proposed as an improvement from the hygienic stand- 
point, on the following grounds: In the first place, it is very desir- 
able to keep the cold air from pouring down upon the heads of the 
stokers and firemen, steeped in perspiration ; and, in the second place, 
the arrangement will give the admitted air a chance to do more ven- 
tilating work before it can make its escape through the centrally lo- 
cated exhaust pipe. In its passage from the sides of the room to the 
center it passes the breathing zone of the men at work, and this fur- 
nishes them with the necessary oxygen before escaping. The deeper 
down the cool, imprisoned air is carried in case of a hot room, the 
greater the distance which it will have to make while it becomes hot 
and rises, and the greater also its ventilating work will be before it 
can escape again. 

Beneath the boiler-room floor the figure shows some of the drains. 
On the extreme right may be seen the large main drain, nearest the 
middle line, where the bilge is located, there are the two independent 
bilge suction-pipes. The secondary drains, as well as the double- 
bottom floor and drain-pipes, may also be seen. Fig. 33 represents one 
side of a vertical section through the ship, where the engine-rooms are ; 
the points shown in this figure are the same as those shown in the pre- 
ceding. 






THE SHIP. 317 

The amount of cubic air-space for the living quarters of the 
crew, though still stingily dealt out on board many of the modern 
warships, may perhaps be regarded as all that can be expected under 
the present strenuous circumstances. With a crew of from six to 
eight hundred men on a battleship, with the constantly increasing 
number of officers required on board, and the ever-increasing addi- 
tions in new apparatus and machinery from year to year, the con- 
structor of such a ship has indeed a large contract on hand, if he is 
to furnish quarters for all, that are to be satisfactory from all points 
of view. From the point of view of sanitation, of course, if any one 
thing is more important than another, that thing is pure air. For 
no one can study thoroughly the history of sanitation in ships, its 
gradual and slow development in connection with life at sea and in 
ships, without coming to the conclusion that human overcrowding or 
its equivalent, bad air, has been the most constant and ever-present 
factor in contributing to render such a life unhealthful. Paradoxical 
as it may seem, it is nevertheless a fact recorded in history, that men 
in ships, at work below decks, have suffocated from want of air, while a 
gale of wind was blowing outside. The recognition by ship-builders 
and of all maritime nations of the present day, of the fact that a cer- 
tain minimum amount of cubic air-space should be allowed every living 
man on board and that an efficient ventilation, besides, is to be main- 
tained, may, therefore, with excellent reasons, be regarded as a signal 
victory over the conditions of the past and as the most important 
achievement of modern marine sanitation. 

Although there are no laws in existence in any navy with regard 
to the cubic air-space to be allowed per man on board a warship, such 
as are to be found for merchant vessels and to which the naval con- 
structor or commander is absolutely obliged to conform, the neces- 
sity for some definite allowance is, nevertheless, so urgent, that it 
practically always forms one of the important factors in the calcula- 
tions in the designs for every new vessel. The result, of course, 
as might be expected, is not a uniform one, varying with the indi- 
vidual ideas of the designer, all the way from 2 to 5 cubic meters, 
or from 70 to 175 cubic feet. 

Some very interesting, as well as instructive, calculations as re- 
gards the allowance of cubic air-space on board warships have been 
furnished us by Dr. C. M. Belli, of the Royal Italian Navy, quite 
recently. Belli, in his hygienic report on the second-class battleship 
Varese, has calculated with great exactness, as well as judgment, the 
actually available air-space per man under different conditions. 



318 



TEXT-BOOK OF HYGIENE. 



Making due allowance for the number of men occupying the different 
sleeping quarters, and deducting the number that is always expected 
to be on duty in other parts of the ship under the usual routine in 
force, and which latter varies in accordance with the whereabouts of 
the vessel whether in port or at sea, he arrives at the conclusions 
shown in the succeeding table: — 

Table XLVIII. 







« a 




c £ 


«fi 


Sleeping Quarters 


o 
■S.S 

3 


Total Cub 

Air-space 

meters 






5 ® 


Gun-deck, forward . . 


30 


200 


6.66 


8 73 


13.33 


14 " amidship . . 


300 


1,562 


5.20 


6.50 


10.40 


Berth deck, forward . . 


20 


161 


8.05 


10.60 


16.10 


" " amidship . 


50 


452 


9.00 


11.30 


18.08 


" " aft ... . 


50 


234 


4.68 


5.80 


9.36 



Although the above calculations show a most generous provision 
of air-space and speaks well for the sanitary provisions made in the 
Italian Navy, calculations on the same principles as those made by 
Dr. Belli on other warships would no doubt reveal the fact that the 
actually available breathing space for the men is greater than the cal- 
culated air-space is. Notwithstanding, however, this deduction, it is 
also a matter of exact calculation that the available breathing-space 
on some of our own vessels does not come up to one-half of the al- 
lowance shown in the above table as existing on the Varese. 

2. Cleanliness. — Our conception of the term "cleanliness" in 
general varies quite considerably at the present time from what it 
was in prebacterial times. While, for instance, not many years ago, 
the surgeon was quite confident that his hands were clean when he 
had scrubbed them in soap and water, continued inquiry and investi- 
gation have convinced him since then that absolute cleanliness of the 
hands is practically unattainable. The methods employed for pro- 
ducing absolute cleanliness of persons and things are so complex 
and require so much professional knowledge that they will probably 
always remain in the possession of the professional few and never be 
mastered by the lay masses. 

Not long ago, a ship, for instance, was considered quite clean 
when its decks were soaked in salt water, its atmosphere saturated 
with moisture, and a smell of turpentine and paint permeated the 
living spaces. After an expensive experience of many years, we have 



THE SHIP. 



319 



found out that a wet ship is not necessarily a clean ship; that damp- 
ness on board a ship is, indeed, one of the conditions favoring bac- 
terial growth and the perpetuation of epidemics. Still, it would not 
be hard to find a deck officer, even at the present day, on a modern 
ship, who would not express great astonishment if told that his clean- 
looking ship was nevertheless in a dangerously unsanitary condition. 
Much missionary work is yet required to generalize the knowledge of 
the principles of ordinary cleanliness. 

The problem of cleaning the decks of a ship is nearing its solu- 
tion on those vessels in which linoleum has been used for deck cover- 
ing. Here, the daily deluge with salt water has ceased to be neces- 
sary, and a moist wiping is both sufficient and effectual in producing 
the ordinary state of cleanliness. The atmosphere between decks 
has become much drier since this change occurred. But, unfortu- 
nately, there is still a considerable number of officers in the service 
who cannot get away from the antiquated system of giving the ship 
under their command a daily "ducking," and the sanitarian, there- 
fore, finds it still necessary sometimes to remonstrate. 

That the old fight for dry decks was really founded on good and 
sufficient grounds has been abundantly shown by the morbidity 
statistics. Friedel, quoted by Plumert, compared the morbidity be- 
tween two English ships, the Centurio and the Conqueror. On board 
the former none but dry holy-stoning was practiced, while on the 
latter the decks were scrubbed after the usual manner, by a daily 
wetting with plenty of salt water and a more thorough weekly one. 
The morbidity records on the two vessels were as shown in the suc- 
ceeding table : — 

Table XLIX. 



Diseases 


Centur'o 


Conqueror 


Fevers 


4 

2 

132 

62 

i89 


99 


Pneumonia , 


33 


Catarrh of respiratory organs 

Sore throat. , 


198 
179 


Dysentery 


10 


Skin diseases 


257 






Summary 


389 


776 



The medical officer, while rarely consulted with regard to the 
general method of keeping the ship clean, is often asked for sugges- 
tions when the bilge is to be cleaned. On this subject he should, 
therefore, be able to give expert advice. The method of treating the 



320 TEXT-BOOK OF HYGIENE. 

bilge, in most cases, consists in a combination of the process of cleans- 
ing with salt water with some process of disinfection. 

In dealing with the bilge, it is by no means an indifferent matter 
whether the contents of the bilge are pumped out into the sea-water 
before being disinfected, or whether their disinfection is to be ef- 
fected first. The bilge-room may contain infectious germs which it 
is not safe to pass on into the waters in which the ship lies at anchor. 
Then again, the mixing of the disinfectant with the bilge-water, 
having to be done very thoroughly and so that all parts of the bilge 
will be brought into intimate contact with it, it will make consider- 
able difference in the result and the method to be employed whether 
the ship is under way or whether she lies quietly at anchor. When in 
motion all parts of the bilge-room will naturally be deluged with the 
disinfecting fluid ; when at anchor, an artificial circulation of the dis- 
infectant must be started with pumps and pipes. The fluid from the 
most dependent portion of the bilge, usually aft, must be pumped 
forward, whence it runs aft again by simple gravity, and thus circu- 
lates through the entire bilge space. 

In the experiments of Koch and Gaffke on the Freya and Hydne, 
the disinfecting fluid w r as first mixed with the bilge-water and, the 
ship lying quietly at anchor, the mixture was pumped from aft forward, 
thus causing it to circulate and become thoroughly mixed. After this 
disinfected bilge-water had been pumped out, enough disinfecting 
fluid was put into the bilge-room to make it rise to the same level 
occupied by the bilge-water previously disinfected and pumped out. 

The results obtained by Koch and Gaffke are summed up in the 
following conclusions: (1) With corrosive sublimate the most resist- 
ing bacilli may be destroyed; (2) corrosive sublimate must be added 
to the bilge-water in sufficient quantity to produce the reaction of mer- 
curic salt; (3) the mixing must be thorough; (4) the disinfection 
may be regarded as accomplished after an exposure of 18 hours; (5) 
after the bilge-room has been rinsed out four times, the amount of 
mercury remaining behind is so small that it is harmless. The 
strength of the solution to be employed is 7 : 2-3000 and salt water is 
the usual solvent. After the disinfection the bilge-room is dried and 
its floor and sides covered with minium paint. In the German 
service the bilge is cleaned in this manner once in two weeks. 

3. Disinfection. — The naval surgeon is rarely called upon to su- 
perintend the disinfection of an entire ship. This is usually done at 
quarantine stations, where the necessary appliances and machinery 
will be found in constant readiness, with a trained personnel to run 



THE SHIP. 321 

them. There are, however, many minor disinfections to be done on 
board every ship which the ship's surgeon must be prepared to exe- 
cute, and which, to do them well, require, nevertheless, a perfect 
knowledge of the art of disinfection and its practical applications in 
all the various branches on his part. 

While in civil life we may make a theoretical distinction between 
sanitary science and hygiene, or between a mere sanitarian (whose 
duty it is to prevent) and the hygienist or, in this case, the profes- 
sional disinfector (whose duty it is to remove the infection after it 
has invaded a ship), the naval surgeon must be both and cannot well 
afford to draw a strict line between these two functions if he is to do 
his full duty by his command. Besides, the whereabouts of war 
vessels are not always convenient to the regular disinfecting stations. 

A vessel, especially a war vessel, is rarely so badly infected as 
to need a disinfection throughout. There is no more reason for fumi- 
gating the hold of any vessel because a case of measles has appeared 
in the cabin or the steerage, than there is for disinfecting the base- 
ment of a tenement on account of the appearance of a case in one 
of the upper stories of the building. In a wooden vessel or iron mer- 
chant ship, with free communications between the various compart- 
ments, the danger of spreading any contagion throughout all parts of 
the ship is, of course, very great, but on a battleship, for instance, 
with its two hundred separate compartments, this danger is consider- 
ably less apparent. 

Of the utmost importance, however, is it to. choose the proper 
method in special cases. In this respect, the naval surgeon finds 
himself frequently in a difficult position because of being obliged to 
devise both the means and the apparatus in order to gain his ends. 
He will then realize that nothing short of a thorough preliminary 
training in the principles and practice of the art can ever help him 
out of the difficulty. 

Sometimes, the composition of the vessel to be disinfected will 
determine the choice of the method. A wooden vessel, for example, 
requires a most thorough mechanical cleansing and a longer exposure 
to germicidal agents than an iron one, in order to insure penetration 
and thorough disinfection, on account of the spongy nature of the 
wood, as compared with the smooth surfaces of iron plates. 

It is sometimes of as much importance to know what to disin- 
fect as how to do it. Thus, the cargo of a vessel is rarely infected 
except in case of plague, where the rats carry the infection into the 
deepest parts of the ships and bilges. The rats must be thoroughly 

21 



322 TEXTBOOK OF HYGIENE. 

destroyed, and after their destruction so handled that the infection 
cannot spread from the cadavers. In the disinfection of living spaces 
it should always be remembered that metal and all bright work are 
ruined by sulphur and bichloride and that, therefore, the use of for- 
maldehyde and carbolic acid must be resorted to instead. In using 
steam it must be kept in mind that leather and furs are ruined by it. 
When water-tanks are suspected of harboring the larvae of mosquitoes 
and the ship happens to be in salt water, the water may safely be 
pumped out, because the larvae, neither of anopheles nor of stegomyia, 
ever develop in salt water. When, however, the ship is in sweet 
water, petroleum should be first employed. In case the water-tanks 
are infected with the germs of cholera, typhoid, or dysentery, the 
water in them should in all cases be thoroughly disinfected or boiled 
by steam. A vessel known to be infected with yellow fever should 
a' ways be given a preliminary fumigation with sulphur or pyrethrum 
powder, before being inspected, in order to either kill or benumb the 
infected insects and thus protect the inspectors. 

On the broadest general principles, while steam and formaldehyde 
must be considered the best agents for the disinfection of bedding and 
clothing, as well as living spaces, there are a number of infectious 
diseases that require special treatment and consideration. Thus, dur- 
ing epidemics of cholera special vigilance must be kept upon the 
water supply and the pipe connections ; in case of plague, it is to rats 
that we must pay special attention; in yellow fever, certain species 
of mosquitoes must be destroyed; in case of the exanthems, bedding, 
clothing, and the patient's skin must receive the lion's share of our 
efforts. In all cases alike, the ship's decks must be disinfected, since 
Belli has shown in an experimental study that the ordinary methods 
of scrubbing with either salt water or lye, as is commonly done, does 
not expedite the disappearance of infectious germs. 

The most important disinfecting agents that should be kept on 
hand aboard every sea-going vessel are sulphur, steam, formaldehyde, 
lime, bichloride of mercury, and, of late, coke must be added to the 
list. Sulphur, for some time in disrepute, on account of its lack of 
penetrating power and its failure to kill spore-bearing germs, has re- 
cently regained part of its lost prestige, since it became known that 
it kills mosquitoes and other disease-bearing animal parasites. The 
best method for ships' use is the iron-pot method. The sulphur is 
usually used in lumps that are saturated with alcohol and then lit. 
Five pounds of sulphur for each 1000 cubic feet of air-space pro- 
duce a 5 per cent, gas, which is sufficient to kill all non-spore-bearing 



THE SHIP. 323 

organisms within sixteen hours. Care should be taken that the articles 
to be treated by this method are not too dry. 

Steam is perhaps the most widely used disinfecting agent, as 
well as the most valuable of any used on board ships. Steam-pipes 
may be found conveniently located in almost any part of a ship, and 
can be tapped for a supply of steam. In case no regular steam dis- 
infecting apparatus is at hand, such an apparatus may be extemporized 
and made out of a vinegar or wine barrel or some iron water-tank. 
Streaming steam has the same power as boiling water, and an exposure 
of half an hour is generally sufficient to kill very resisting spores. 
It may, therefore, safely be used and depended upon for destroying 
the infectious agents of any of the communicable diseases. It should 
be remembered that steam shrinks woolens and injures silks, it ruins 
leather, fur, skins of all kinds also rubber shoes, mackintoshes, and 
other articles of impure rubber. 

Formaldehyde. — A gas is, of course, the ideal form of a disinfect- 
ant, and formaldehyde comes, perhaps, nearer to that ideal than any 
other gas, in spite of the fact that it has some very decided limitations, 
not the least of which is its lack of penetrating power. Solutions, 
unless immersion can be maintained for a long enough time without 
injury to the material, are not so valuable. Several years ago, von 
Esmarch devised a method by means of which it was thought possible 
to eliminate the shortcomings of both steam and formaldehyde. The 
method aimed at a combination of steam and formaldehyde in a 
chamber in which the air was rarified at the same time. By adding 
the vapor of formaldehyde to steam it was hoped that steam might be 
used at a lower temperature than 100° C, and thus its injurious ef- 
fects on some of the fabrics be eliminated. By causing a partial 
vacuum in the disinfecting chamber it was hoped that the penetrat- 
ing effect of formaldehyde could be materially increased. Kister and 
Trautmann, in some recent experiments with von Esmarch's method, 
made with the object of testing its applicability on a large scale, ob- 
tained results that were not quite as promising as they had been led to 
expect. Although the combination of steam with a 2 per cent, atmos- 
phere of formaldehyde gave evidence of increased disinfecting power, 
it was noted that the mixture, at a temperature of 75° C. and under 
a reduction of the pressure equal to 520 millimetres, failed to kill 
all the spores and did not uniformly penetrate all parts of the cham- 
bers. The method, however, seems promising, and its further perfec- 
tion will be only a matter of time. 

Formaldehyde occurs in the market in several forms. The 40 per 



324 TEXT-BOOK OF HYGIENE. 

cent, solution is known as formalin, and this is sometimes used for 
the generation of the gas in a speeial generator. Ten ounces of this 
fluid are considered quite sufficient for each 1000 cubic feet of air-space. 
Sometimes the gas is developed directly from wood alcohol. When the 
vapor of wood alcohol is passed over incandescent platinum, the alco- 
hol is reduced to an aldehyde. By the use of the Kuhn lamp three 
pints of wood alcohol may be reduced in two hours, and the amount 
of gas thus produced is said to be sufficient for the disinfection of 
1000 cubic feet of space. For the purpose of disinfecting clothing 
in a trunk, which often needs to be done when officers return from 
leave of absence and report infectious diseases in their families, not 
less than 50 cubic centimetres of formalin for each cubic foot of 
space is required. (Eosenau.) Mail matter is ordinarily disinfected 
by clipping the corners off the envelopes and introducing a few drops 
of formalin with an eye-dropper, and several drops are also put 
on the outside cover and the whole shut up in a tight box, which 
is then placed in a warm room for six hours. The box should 
be opened out of doors. Formalin is also a convenient disinfect- 
ant for urine, excreta, and sputum, because of its possessing the 
property of combining with the albuminous matters without causing 
their coagulation. On account of its nontoxic properties it is, more- 
over, often employed in the disinfection of food-products. Large 
quantities of bulbs, roots, nuts, fruits, and similar articles, coming 
from infected districts, are treated by immersion into a 5 per cent, 
solution of formalin without harm. Bulbs so treated keep from 
rotting for a long time. 

Lime. — Milk of lime, which is slaked lime mixed with about four 
times its volume of water, is one of the most useful disinfectants 
for excreta and privy-vaults. Chlorinated lime, in the United States 
Army officially prescribed in the form of a 4 per cent, solution for 
use in the disinfection of the excreta from the sick, combines the effect 
of both lime and chlorine. When used for ships' holds or rooms, V/ 2 
pounds of it mixed with 6 ounces of strong sulphuric acid are supposed 
to be sufficient to produce the purification of 1000 cubic feet of space. 
As is the case with sulphurous acid, chlorine gas acts more energetically 
in the presence of moisture. 

Mercuric Chloride. — One of the most popular of the disinfect- 
ants is mercuric chloride. A solution of 1 : 1000 will surely kill all 
spore-bearing organisms at ordinary temperature within half an hour. 
Articles of clothing may be thoroughly disinfected by immersion into 



THE NAVY RATION. 325 

a solution of 1: 2000 for two hours; a solution of 1: 15,000 inhibits 
both fermentation and putrefaction. 

Carbon Monoxide. — In carbon monoxide we possess one of the 
most efficient gases for the destruction of rats in ships. Nocht and 
Giemsa have recently devised an ingenious apparatus in which the gas 
is produced by the incomplete combustion of coke. Part of the heat 
produced by the combustion is used to furnish the steam necessary 
for running a water-pump and ventilator. The gases resulting from 
the combustion of coke are heavily charged with carbon dioxide, the 
pressure of which prevents them from forming an explosive compound 
when mixed with air. This protective action of C0 2 is secured when the 
latter reaches an amount equal to twice that of the carbon monoxide 
content. As determined by the apparatus of Orsat, the composition 
of the gaseous mixture produced in the generator is CO, 4.95 per 
cent.; C0 2 , 18 per cent.; and N., 77.05 per cent, by volume. Four 
hundred and five cubic metres of the gas can be produced in one hour. 
The gas has a specific gravity of 1085. Before beginning the disin- 
fection the men must leave the ship. In order to kill all the rats in 
a ship, it suffices to generate an amount of gas which equals one-half 
to three-quarters the capacity of the ship. The process of disin- 
fection being over, all that is necessary, in order to get rid of the gas, 
is to start the ventilators and open the hatches. This may be done 
after an exposure of six hours. 

Mice are used for testing the atmosphere for CO. These ani- 
mals, which are very sensitive to CO, must be found alive after a two- 
hours' residence in any compartment, before the ship is pronounced 
safe for re-occupancy. The method is not only reliable and thorough, 
but also quite inexpensive. 

THE NAVY RATION. 

While it cannot be expected, in the limited space allotted to this 
article, that we enter at all into the special physiology of nutrition 
or into the chemistry of food-stuffs, it is, on the other hand, unavoid- 
able and necessary to touch upon those of the leading principles and 
methods according to which the nutritive values of those of the food- 
substances that are in common use on board sea-going vessels, and 
included in the navy ration, are ordinarily determined. 

In the ordinary walks of life a man chooses not only what articles 
he eats, but also how much of these he thinks he needs, and the free 
play of his instincts generally leads him to select from a bill-of-fare 
the diet best adapted for his maintenance. In naval and military 



326 TEXT-BQOK OF HYGIENE. ' 

organizations this free choice or selection as regards a man's diet is 
greatly limited, inasmuch as the latter is provided for him by some 
one else. Hence it will readily be seen how very important it is that 
this provided diet should answer in all respects to the full require- 
ments of the average working man. 

The diet-list made out on board ship ought to differ, therefore, 
from an ordinary bill-of-fare, in giving, upon careful examination, the 
results characterizing a perfectly constructed and in every respect 
complete meal. The meals for the day, to be called perfect, must 
show that they contain in proteids, fats, and carbohydrates not only 
the proper amounts, but also the right relative proportions of each. 
When the examination shows that this is the case, then our list of 
articles ceases to be a mere "bill-of-fare" and becomes a "ration," 
intended to meet all the required needs of the normal, working human 
organism for a period of twenty-four hours. Since the distribution of 
the different articles of food-stuffs, on board ship, at any rate, is left 
to the commissary yeoman, a man not generally in possession of the 
knowledge required to perform that duty according to the best prin- 
ciples of the physiology of nutrition, and since, moreover, the influ- 
ence ' of the continuous faulty distribution of food-stuffs upon the 
larger number of men must prove disastrous in the long run, it be- 
hooves the sanitary officer to keep an eye on the diet of his men and 
correct any mistake made in this respect. He should, therefore, be 
familiar with the methods employed to determine the food values of 
any diet, as well as know when a diet is complete in all respects, and 
when it is not. 

The food value of any edible substance is generally expressed 
by the number of calories or heat units which one gram or any other 
definite quantity of it will develop when completely burned in a 
calorimeter. The amount of heat that is developed during the com- 
bustion, for instance, of one gram of a substance in a calorimeter is 
exactly the same that is produced when one gram of the same sub- 
stance is completely oxidized within the body. In a living organism 
about 30 per cent, of this value can be put out in the form of me- 
chanical work, while the remainder passes off in the form of heat. 
We know, thanks to the researches of Voit, that an average adult 
laborer performing his daily work puts out in mechanical work and 
heat the equivalent of about 3000 calories. In order, therefore, that 
the man shall not lose his weight, his daily diet must be such as to 
balance his loss and have a combined caloric value of at least 3000 
units. If we furthermore take into calculation that about 400 of these 



THE NAVY RATION. 327 

units, at least, must come from proteids, 500 from fats, and the re- 
mainder from carbohydrates, we have the most necessary data for 
the calculation of the man's diet. Thanks to the labors of Voit and 
Rubner and their numerous pupils, these determinations have been 
greatly simplified in recent years. 

Outside conditions, personal and racial habits, climate, age, and 
sex may alter the relative proportions of proteids, fats, and carbo- 
hydrates in a certain diet; but the above proportions must stand as 
answering to the average requirements of an adult workingman in 
a temperate climate. In calculating the dietary value of a ration we 
must also allow for an unavoidable loss in the preparation of the differ- 
ent parts of it. In meats a loss of 20 per cent, of the raw material is 
generally allowed for bones ; in salted herring, 37 per cent. ; in pickled 
herring, 29 per cent. Potatoes boiled and then peeled lose 7 per cent. 
Potatoes peeled raw lose 30 per cent. In the case of eggs 10 per cent, 
in weight is deducted for the shells, etc. Another source of loss from 
the gross weights is in the different degrees of digestibility of foods, 
for which allowance must also be made. As a general rule, animal 
foods are much more completely digested than foods of vegetable 
origin. Eubner has shown that the proteids from meat and milk dis- 
appear almost entirely, while those from bread, and especially vege- 
tables, reappear in the feces in considerable proportions. 

A simple and approximately accurate method for calculating the 
nutritive value of a diet has recently been published by Schumburg. 
He makes a slight difference in the food value between animal and 
vegetable proteids, giving the former a value of 3.5 and the latter a 
value of 3.1. The fats have a value of 8.8 and the carbohydrates one 
of 3.7. Given, then, the various constituents of a diet, expressed in 
proteids, fats, and carbohydrates, their weight stated in grammes, 
multiplied by their respective values, the several amounts added to- 
gether would give a sum corresponding to the total food value of a 
diet in numbers of calories or nutrient units. Remembering that a 
sufficient diet for an adult workingman must have at least 2000 
nutrient units, and that the proportion of proteids, fats, carbohydrates, 
and salts in a complete diet should be as 150. 100, 500, and 35, we 
should have an easy and simple method of ascertaining and con- 
trolling the dietary value of any meal. 

It is on these principles, and with the aid of the usual tables of 
the food values of the different articles entering into the composition 
of a diet to be found in every work on physiology or hygiene, that 
the following diet table of the new naval ration has been worked out. 



28 



TEXT-BOOK OF .HYCJ1ENE. 



A reduction of about 25 per cent, of the quantity of every article 
in the table, with the exception of the usual quantities of bread, but- 
ter, coffee, milk, and sugar, was made for certain necessary and un- 
avoidable waste which occurs in their preparation. In calculating the 
food values of the customary quantities of bread, butter, coffee, milk, 
and sugar which are served out at every meal, the value of coffee as a 
food was disregarded. It may be added that the coffee is replaced, 
especially for supper, by cocoa or tea. 



Table L. 

Diet table prepared from one week's allowance of the new United States naval ration. 

SUNDAY. 





Weight 

in 
Grams 


Contents in 


Grams 


In Nutrient Units 




Food Allowed 


Protein 


Fats 


Carbohy- 
drates 


Protein 


Fats 


Carbohy- 
drates 


Sum. 


Breakfast: 


135 
90 


32.8 
15.8 


2.0 

19.8 


66.2 


101.7 
55.3 


17.6 
174.2 


244.9 


364.2 


Pork 


229.5 














16.8 


19.9 


170.7 


52.6 


175.1 


631.6 


859.3 


















209.6 


366.9 


876.5 


1,453.0 












Dinner: 


360 
270 


72.2 
5.4 


32.4 
.5 




252.7 
16.7 


285.1 
4.4 




537.8 


Potatoes, mashed. . . . 


55.9 


206.8 


227.9 






16.8 


19.9 


1T0.7 


52.6 


175.1 


631.6 


859.3 


















322 


464.6 


8 8.4 


1,625.0 












Supper: 


ro 

112 


27.5 
.2 

16.8 


C2.0 
"lo'i" 




96.2 

.6 

52.6 


457.6 
'l75.i" 




553.8 


Jtlly 


36 
170.7 


133.2 
631.6 


133.8 




859.3 


















149.4 


632.7 


764.8 


1,546.9 















Total nutrient units in day's ration, 4,625. 

MONDAY. 



Breakfast : 


90 
180 


10.8 
17.1 
16.8 


4.0 
136.8 
19.9 


5 .2 


33.5 
63.3 
52.6 


35.2 

1203.8 

175.1 


193.1 


261.8 




1 267.1 




170.7 


631.6 


859.3 
















149.4 


1,414.1 


821.7 


2,388.2 












Dinner : 
Beef, roasted 


360 
180 

"seo" 


80 3 

41.0 

IB. 8 

7.2 


102.9 

3.2 

19.9 

.7 




281.0 
127.1 
52.6 
22.3 


905.5 

28.2 

175.1 

6.2 




1 186.5 


94.3 
170.7 
74.5 


348.9 
631.6 
275.6 


504.2 


Bread, butter, etc 

Potatoes 


859.3 
304.1 












483.0 


1,115.0 


1,256.1 


2.854.1 














Supper : 
Cold beef. . . . 


ISO 

10 
i;0 


40.1 

11.7 
.4 

16.8 


51.5 

1.8 

"l9.9" 




140.3 

36.3 
1.2 
52.6 


453.2 

15.8 
"l75.i" 




593.5 


Pudding— 


141.3 

86.8 
170.7 


522.8 
323.2 
631.6 


574.9 




324.4 




859.3 


















230.4 


644.1 


1,477.6 


2,352.1 








1 





Total nutrient units in day's rations, 7, 



THE NAVY RATION. 



329 



Table L — (Continued.) 

Diet table prepared from one week's allowance of the new United States 
naval ration. 

TUESDAY. 





Weight 


Contents in Grams 


In Nutrient Units 




Food Allowed 


in 
Grams 


Protein 


Fats 


Carbohy- 
drates 


Protein 


Fats 


Carbohy- 
drates 


Sum. 


Breakfast : 
Hash- 


180 

345 

45 


27.5 

6.9 

.8 

16.8 


52.0 

.7 
1 




96.2 

21.4 

2.5 

52.6 


457.7 

6.2 

.8 

175.1 




553.8 




71.4 


264.2 

17.0 

631.6 


291.8 




20.3 




19.9 | 170.7 


859.3 
















]72.7 


639.7 


912.8 


1,725.2 










Dinner: 
Soup — 


90 

360 

45 

90 


21.9 

63.0 

.6 


1.4 

79.2 

.1 


44.1 


67.9 
220.5 

1.8 


12.3 

697.0 
.8 


163.2 


243.4 


Pork 


917.5 




2.0 


7.4 


10.0 


Pickles 




Bread, butter, etc. . . . 


16.8 


19.9 1 


52.6 


175.1 


631.6 


859.3 
























342.8 


885.2 


802.2 


2,030.2 














Supper : 
Stew- 


360 
90 
15 
45 

180 


6.8 
7.8 

"".2" 
40.1 
16.8 


1.2 

.9 

12.2 

51.5 
19.9 


11.9 
67.0 


21.0 
24.2 


10.6 

7.9 
107.4 

453.2* ' 
175.1 


44.0 

247.0 


75.6 




279.1 


Butter 


107.4 




43.4 


.6 

140.0 

52.6 


161.6 
"631.6"' 


162.2 


Cold beef 


593.2 




170.7 


859.3 



















238.4 


754.2 


1,034.2 


2,076.8 













Total nutrient units in day's ration, 5,832. 



WEDNESDAY. 



Breakfast : 


180 
90 


43.8 
15.8 


2.8 
19.8 


88.2 


135.8 
55.3 


24.6 
174.2 


326.3 


486 7 


Pork 


229 5 










Bread, butter, etj 




16.8 


19.9 


170.7 


52.6 


175.1 


631.6 


859.3 












243.7 


373.9 


957.9 


1,575.5 












Dinner: 
Sausages (Frankfort) . 


225 
500 
270 
180 


39.4 
8.0 
3.5 
3.5 

16.8 


90.0 

1.5 

.5 

.4 

19.9 




137.9 

24.8 
10.8 
10.8 
52.6 


792.0 
13.2 
4.4 
3.5 

175.1 




929 9 


28.0 

21.9 

37.3 

170.7 


103.6 

81.0 

138.0 

631.6 


1J1 6 




96 2 




152 3 


Bread, butter, etc 


859.3 












236.9 


988.2 


954.2 


2,179.3 












Supper : 


110 
4,5 
10 
45 

110 


9.9 
14.0 

" "i" 

24.5 
16.8 


.5 
11.0 

8.4 

.1 

31.6 

19.7 


84.7 
1.0 


30.7 
49.0 


4.4 

96.8 

73.9 

.8 

278.0 

175.1 


313.4 
3.7 


348 5 




149 5 


Butter 


73 9 




2.0 


1.5 
85.7 
52.6 


7.4 


9 7 


Beef, corned 


363 7 


170.7 


631.6 


859 3 


















219.5 


629.0 


956.1 


1,804.6 













Total nutrient units in day's rations, 5,559.4. 



330 



TEXT-BOOK OF HYCUENE. 



Table L .— ( Continued. ) 

Diet table prepared from one week's allowance of the new United States 
naval ration. 

THURSDAY. 



Total nutrient units in day's ration, 5, 





Weight 

in 
Grams 


Con 


tents in Grams 


In Nutrient Units 




Food Allowed 


Protein 


Fats 


Carbohy- 
drates 


Protein 


Fats 


Carbohy- 
drates 


Sum. 


Breakfast : 
Stew- 
Beef 


180 

270 
45 
30 
25 


40.1 
5.5 
.6 
.4 

.3 

16.8 


51.5 
.5 
.2 

19.9" 




140.0 

17.0 

1.5 

1.5 

1.0 

52.6 


453.2 
4.4 
1.7 

175. i" 




593 2 




55.9 
5.0 
3.0 
1.0 
170.7 


206.8 

18.5 

11.1 

3.7 

631.6 


228 2 




21.7 




12 6 




4 7 




859.3 


















213.6 


634.4 


871.7 


1,719.7 












Dinner: 


360 
110 
135 

180 


56.1 
1.8 
1.7 
3.5 

16.8 


94.3 
.1 
.3 

.4 
19.9 




196.0 

6.0 

5.5 

10.8 

52.6 


829.8 

.8 

3.0 

3.5 

175.1 


39! 5*" 

40.7 
138.0 
631.6 


1,025.8 
46.3 




10.7 

11.0 

37.3 

170.7 




49.2 




152.3 




859 3 












1 






1,012.2 


849.3 


2,132.9 














Supper : 
Rice 


110 

72 
80 


7.2 
6.0 
.4 


1.1 
6.0 


86.4 


22.3 
21.0 
1.2 


9.6 

52.8 


319.6 


3515 




73.8 




77.2 


285.6 


286.8 






Beef, corned, c Id . . . 


135 


21.0 
16.8 


35.4 
19.9 




73.5 
52.6 


311.5 
175.1 




385.0 


170.7 


631.6 


859.3 












1 




270.6 


549.0 


1,236.8 


1,956.4 






1 





FRIDAY. 



Breakfast : 


180 
315 
22 


27.5 

6.3 

.1 

16.8 


52.0 
.6 

' 19.9 ' 




96.2 

19.5 

.3 

52.6 


451.6 
4.4 

' 175.1 ' 




547.8 




65.2 

2.0 

170.7 


241.2 

7.4 

631.6 


265.1 




7.7 




859.3 


















168.6 


631.1 


880.2 


1,679.9 












Dinner : 
Mutton, roasted 


360 

180 

16 

360 


273.6 

41.0 

1.2 

7.2 

16.8 


61.2 
3.2 

13.8 

.7 

18.9 


21.6 

94.3 

.1 

74.5 
170.7 


957.6 

127.1 

4.0 

22.3 

52.6 


544.0 

28.1 

118.8 

6.1 

175.1 


79.9 

347.8 

.3 

277.6 

631.6 


1,581.5 
503.0 


Butter 


123.1 


Potatoes, mashed .... 


306.0 
859.3 


















1,163.6 


872.1 


1,337.2 


3,372.8 












Supper : 
Salmon 


270 
90 


57.2 

.7 

16.8 


34.6 
' 19.9* ' 




2C0.2 
1.4 
52.6 


304.5 
' 175.1 ' 




504.7 


Fruit, canned 


7.2 
170.7 


26.6 
631.6 


2.0 

859.3 


















254.2 


479.6 


658.2 


1,392.0 













Total nutrient units in day's ration, 6,444.8. 



THE NAVY RATION. 



331 



Table L. — (Continued.) 

Diet table prepared from one week's allowance of the new United States 
naval ration. 

SATURDAY. 





Weight 

in 
Grams 


Contents in Grams 


In Nutrient Units 




Food Allowed 


Protein 


Fats 


Carbohy- 
drates 


Protein 


Fats 


Carbohy- 
drates 


Sum. 


Breakfast : 
Soup— 


180 
270 
70 
20 
90 


136.8 

5.4 

.8 

.3 

1.2 

16.8 


30.6 
.5 
.3 
.1 
.2 

19.9 


J0.8 
55.9 
6.4 

2.0 

8.0 

170.7 


478.8 

16.8 

2.4 

.3 

3.7 

52.6 


269.3 

4.4 

2.6 

.8 

2.2 

175.1 


40.0 

207.2 

23.6 

7.4 

29.6 

631.6 


788.1 




228.4 




28 6 




8 5 


Turnips 


35.5 




859 3 


















554.6 


454.4 


639.4 


1,948.4 












Dinner : 


70 

360 
50 


17.0 

63.0 

.6 

16.8 


1.0 

79.2 

.1 

19.9 


34.3 


52.1 

220.5 

1.5 

52.6 


8.8 

685.2 

.8 

175.1 


126.9 


187.8 


Pork 


905.7 


Tomatoes 


2.0 

170.7 


7.4 
631.6 


9.7 

859.3 


















323.7 


869.9 


765.9 


1,962.5 












Supper : 
Sausage, bologna 


180 
90 


31.5 

26.5 
16.8 


72.0 
21.6 
19.9 




110.2 
92.4 
52.6 


633.6 
190.0 
175.1 




743.8 


1.8 
170.7 


6.6 
631.6 


289.3 


Bread, butter, etc 


859.3 


















255.2 


998.7 


638.2 


1,892.4 







Our table is intended to show the food values, expressed in pro- 
teids, fats, and carbohydrates, that are contained in the different arti- 
cles of food actually served out to the men during a week on board 
the U. S. S. Prairie. The table, incidentally, shows many points of 
considerable interest that are worthy of study; these I need not point 
out. The cardinal point brought out in the calculation is that the 
average daily number of nutrient units served in the form of food, 
per man, amounts to 5953, just twice the number required by an 
adult workingman of an average weight of 70 kilos. Hence our 
examination has shown conclusively that the new ration, as handled 
on board the U. S. S. Prairie, is overwhelmingly in favor of the 
quantitative sufficiency of the same. 

As regards the relative proportions existing between proteids, 
fats, and carbohydrates, we have seen that they must accord with cer- 
tain percentage requirements. A properly constructed ration must 
contain, according to the accepted standard, 20 per cent, in proteids. 
13 3 / 10 per cent, in fats, and 67 7 / 10 per cent, in carbohydrates. The 
following "table of percentages" is intended to exhibit the results of 
an examination of our ration in this respect : — 



332 



TEXT-BOOK OF HYGIENE. 
Table LI. 

Table of Percentages. 





In per cent. 


Differences 


Pays of the Week 


Proteids 


Fats 


Carbo- 
hydrates 

53.6 

46.8 
48.0 
51.6 
50.9 
44 6 
40.4 


Proteids 


Fats 


Carbo- 
hydrates 


Sunday 

Monday 

Tuesday 


14.8 
11.4 
130 
12.6 
11.3 
24.6 
19.6 


31.6 

41.8 
39.0 
35.8 

37.8 
30.8 
40.0 


-5.2 

-8.6 
-7.0 
-7 4 
-8.8 
+4.6 
- .4 


+18.3 
+28.5 
+25 7 
+22 5 
+24.5 
+17.5 
+26.7 


-13.1 
-20 9 
—19.7 


Wednesday 

Thursday 


-15.1 
-15.8 


Friday 


-22.1 


Saturday 


—26.3 






Average 


15.3 


36.7 


48.3 


-4,7 


+23.4 


-18.4 



In this table the various sums of the nutrient units in proteids, 
fats, and carbohydrates for the three daily meals expressed in per- 
centages, occupy the first three columns and the plus and minus 
deviations from the required normal standard the last three columns. 
The table shows that the fats are in excess of the standard, while both 
the proteids and carbohydrates show marked deficiencies. 

The conclusion reached after an examination of the diet table 
given above is that, from the point of view of sufficiency, the ration 
exceeds the requirements, but apart from this shows certain limi- 
tations. 

WATER-SUPPLY. 

Although all naval vessels and nearly all the larger vessels of 
the mercantile marine are at present supplied with distillers for the 
production of drinking-water from sea-water, they cannot be said to 
be entirely independent of the water-supplies from natural sources 
on shore. Circumstances arise on every vessel, and often at that, 
under which the water-tanks are filled with water from shore, and 
naval sanitarians, therefore, cannot yet afford to disregard the general 
hygiene of water-supplies from all sources. Since, however, this sub- 
ject is treated of in another part of this work, the supply of drinking- 
water from sea-water, as usually done on board ships, will alone be 
spoken of in this connection. 

On board all of the vessels of the United States Navy the so- 
called United States Standard Evaporator is used (see Fig. 35). 
This evaporator is made of several sizes, the largest of which pos- 
sesses a productive capacity of 10,000 gallons of distilled water per 
diem. The general design is identical for all sizes. The apparatus 



WATER-SUPPLY. 



333 




O'etaa+xj 



^ 



Ffire/1 






¥ 



m 



P% 




To < 9»6t/tSB* 




roMAKeufifteg 



.5 e ft w* re/z 



vV-=- 



m- 



m> 



Fig. 39. — Distilling Plant as Installed in Vessels of the United 
States Navy. 



consists of two parts, namely: (1) the evaporator, and (2) the dis- 
tiller, sometimes called the condenser. The evaporator consists of a 
hollow, cylindrical shell, made of steel and placed horizontally. The 
lower half of this cylinder is occupied by tubes running lengthwise 
and fixed in their positions at either end to a pair of plates which 



834 TEXT-BOOK OF HYGIENE. 

permit of the tubes being removed for sealing in their entirety. The 
tubes are connected with the main boilers, from which steam is run 
into them, generally at a pressure not exceeding forty* pounds. The 
sea-water intended for distillation fills that portion of the lower half 
of the cylinder which is outside the tubes, but not quite reaching the 
upper level of the highest tubes. It is, indeed, the intention that the 
tubes shall not be entirely immersed in the salt-water, the upper level 
of which is. on the contrary, maintained on a level considerably below 
that of the tubes. The customary pressure within the shell is about 
ten pounds. By the use of the valves, the density of the sea-water is 
generally maintained at 4 / 32 . T ne tubes of the distiller are made of 
tinned copper or brass ; the joints are soldered. 

Thus we see that the evaporation of the sea-water is caused by the 
heat imparted to it through the steam in the pipes which the sea- 
water surrounds. The steam itself does not mix with the sea-water. 

The distiller or condenser is a cylinder, made of brass or iron 
in various sizes, placed vertically and fitted with straight tubes for 
circulating cooling water, which is made to enter at the bottom and 
discharge at the top. The steam to be condensed passes through the 
distiller in the inverse sense. 

On vessels which are equipped with very large plants for dis- 
tilling water, the apparatus is arranged somewhat differently from the 
above. The work of distilling is divided into two or three stages, 
and thus the working efficiency of the plant is thereby correspondingly 
increased. Under this system, steam from the boilers is used to 
evaporate the water in the first set of evaporators; this evaporated 
steam is used to heat and evaporate the water contained in the sec- 
ond set of evaporators; and this in turn, is made to evaporate the 
water contained in a third set. The steam from the last is finally 
condensed to water in a distiller of the above description. This sys- 
tem more than doubles the actual thermal efficiency of the apparatus, 
but it is not installed except in very large ships, on account of the 
complications in mechanical fittings which it necessitates. 

The precautions usually observed are as follows: (l)The plant 
should be used only when pure sea-water is available. (2) For 
drinking-water, the apparatus should not be used to its full capacity, 
in order to reduce priming or carrying of salt-water directly over 
into the distillate. (3) Tests of the complete plant to be made daily 
to insure tightness of all the joints. (4) The water level in the 
evaporators is to be kept low. (5) When the ship is under way and 
rolling heavily, the plant must be worked at its lowest capacity. (6) 



WATER-SUPPLY. 



335 



The pressure of the cooling water in the distiller is limited by de- 
partmental order to thirty pounds, which is to minimize the danger of 
salt-water leaking into the distiller. (7) Tests' of the distillate are 
to be made every fifteen minutes. 

That the water produced by this evaporator is liable to contain 
certain substances not expected to be present in chemically pure dis- 
tilled water may be seen from the adjoining table, which exhibits the 
results of twenty-two analyses of the water it produces, made on the 
U. S. S. Prairie. 

Table LII. 

Tabulated Results of Twenty-two Analyses of Water Distilled from Salt 
Water by the United States Standard Evaporator. 



U. S. S. Prairie, Gulf of Paria, 
January, 1902 


.° 5 
"3 

o 

a 
a 
< 

V 


03 


BO 

© 

Is 
h 


815 


0) 

.2 ■»'£ 

. a .2 



Orgaaic Matter, 

Represented in 

Milligrams of 

Oxygen per Litre 


3 


+ 



+ 
+ + 

+ 
+ + 

+ 



+ 

+ 

+ 

+ 

+ + 






















9 


+ + 1 





+ + 









9 










+ 











220 
30 
20 
10 
50 
20 
24 

130 

8 

12 

20 

20 

160 
30 
30 
20 
90 
12 
20 
32 
80 
32 


10.0 
5.0 
40 
6.0 

11.0 

16.0 
70 

13.0 
4.0 
4.0 
5.5 
6.0 

10.0 
4.5 
5.0 
5.0 

10.0 
70 
8.0 
6.0 
8.0 
5.0 


0.0 


4 


2.0 


5 


3.5 


6 


1.7 


7 

8 


3.6 
2.0 


9 


3.2 


10 


6.5 


13 


2.0 


14 


3 


16 


3.0 


17 


3.0 


18 


4.0 


20 


4.5 


21 


5.0 


22 


3 


23 


2.5 


25 


2.0 


26 


3 


27 


2 


28 


120 


30 


3 







These impurities are occasioned by defects in the water-making 
plant. The defects consist in slight leaks in the coils of the patent 
evaporator, which contain about forty-eight conical steam- joints, which 
are apt to work loose after long and hard usage. It may be readily 
seen that any leak of boiler steam through any of these joints must 
carry into the distiller whatever impurities it contains, such as salts 
of all kinds, rust, or grease. 



336 TEXT-BOOK OF HYGIENE. 

The do foot can be remedied by filling the coils of the patent 
evaporators with steam from the low-pressure side of the larger third 
evaporator. The effect of this change is to make the evaporating plant 
one of "double effect.'' The steam from the boilers enters the large 
evaporator-coils and evaporates salt-water. The steam from this evap- 
orator, before going to the distiller, is condensed in the coils of the 
two smaller evaporators, and only passes through the distiller to be 
cooled. Of course, any leak from the steam side to the water side 
of the small evaporators involves a slight loss of efficiency, but such 
a leak, no matter how great, can no longer make the distillate impure. 

Besides the impurities due to defects in the central distilling 
plant, we sometimes find that the drinking-water is contaminated 
from other sources. While the water taken from the distiller proves 
to be pure, an analysis of the water taken from any spigot may show 
that it is not safe to drink. Such impurities can be due only to 
dirty water-tanks or to faulty pipe connections. Thus, for instance, 
it will sometimes happen that one of the tanks is used for other pur- 
poses than the storage of the purest drinking-water and, before it 
was cleaned, drinking-water from the distiller is again run into it. 
Iron pipes may cause the water to be contaminated with iron rust, 
and lead pipes may contaminate it with small amounts of lead. All 
this goes to show how necessary it is that the water on board ship 
must be analyzed occasionally, and that the mere fact that the water 
is distilled must not be allowed to throw the sanitarian off his guard. 

With regard to the daily allowance of water per man, there are 
no hard-and-fast rules in the navy according to which this is regu- 
lated. The natural consequence. of this is, as might be expected, that 
the supply varies directly on board the different vessels with the 
individual caprice or the understanding of the officer in command, 
being dealt out liberally on some and parsimoniously on others. 
While there is, generally, enough drinking water allowed, there is in 
all the ships too much economy shown in the supply of the men with 
sweet water for purposes of bathing and washing clothes. 

The result of this false economy is, first, that the men cannot 
keep their skins as clean as they ought to; and, second, for washing 
their clothes, the men with the cleanest habits and instincts will 
often get sweet water from forbidden sources and store it away in 
buckets which they hide in all conceivable places for future use, until 
they are discovered by the inspecting officer, when, of course, they 
not only lose the water, but are reported and punished for the mis- 
demeanor. When it is considered, from a sanitary point of view, that 



WATER-SUPPLY. ;;:;; 

it is economy to be lavish with the water supply, and that especially 
sailors should be so trained that cleanliness of person must become 
for them a habit, it will at once be seen how pernicious this prac- 
tice is. 

The great necessity for a proper care of the skin becomes espe- 
cially apparent in the tropics, where, owing to the increased activity 
of the sweat-glands, skin eruptions and cutaneous abscesses are of the 
most frequent occurrence. Such troubles not only greatly add to 
the discomfort of the men, but are the efficient causes for numerous 
and frequent admissions to the sick-list, resulting in a loss to the 
service of a great many working days. That better facilities for 
bathing, for both officers and men, should be provided on board all 
the ships of the navy than are at present available is a fact upon which 
all officers agree. It is the duty of the sanitarian to do all in his 
power and urge this necessity upon the constructors of new vessels 
whenever he can. 

Since it is, of course, out of the question that a sufficient number 
of bath-tubs be provided for a large ship's company, shower-baths 
can alone be considered for the men. In some of the larger war 
vessels of the German navy places for showers have been provided 
in which fifteen men may receive a douche at one time, so that, accord- 
ing to the calculations of Nocht, 300 men may be served in two hours' 
time, at an average expenditure of 1200 gallons of water. Since, 
besides this, 1% gallons is the minimum allowance of water per man 
and per day for purposes other than drinking, we have here a basis for 
calculating the total water-supply needed for twenty-four hours and for 
the capacity of the distillers that are required to furnish the same. 

The first receiving ship in the United States navy on which the 
wash-rooms and bath-rooms for the men have received the attention 
at all commensurate with their importance is the recently converted 
ship Lancaster at the Navy Yard, League Island, Pennsylvania. 
This ship provides accommodations for 720 men. The wash-room is 
on the forward part of the spar deck, having a cubic capacity of 3584 
feet, and contains 12 reversible wash-basins, all supplied with hot and 
cold water. The bath-room has a cubic capacity of 2040 feet and 
contains 8 showers, supplied with hot and cold water, the temperature 
of which may be regulated. This very excellent arrangement calls for 
the widest possible general application on all sea-going vessels of 
the navy. 

Before leaving the subject of the water-supply, a few words must 
be added on the scuttle-butt question. The scuttle-butt, so-called, 



3^8 TEXT-BOOK OF HYGIENE. 

is an iron tank filled with water and provided with one or more 
spigots near the bottom of it, from which the men take their drinking- 
water by means of a cup. This cup is suspected of being the means 
of the spread of infectious disease on shipboard, especially during the 
prevalence of epidemics like diphtheria, mumps, etc. Numerous 
recommendations have been made to eliminate this danger, one of 
the most recent ones being that of Dr. C. F. Stokes, U.S.N., who sug- 
gested that the cup be immersed in a solution of formaldehyde of 
1 : 2500 while not in use. While this practice would undoubtedly 
diminish the chances of transmission of infection, it could not be 
said that it would altogether prevent it. 

When we consider that the feeling of thirst generally manifests 
itself in a number of men at the same time, and that often from 
twenty to thirty men may be observed standing in a line and wait- 
ing their chances to use the same cup, the paraldehyde solution would 
not get a chance to act on any infectious material left on the cup 
by a previous drinker before the next one came along. The only 
possible way of preventing the transmission of infection by means of 
the cup is to do away with the cup altogether, and serve water through 
a fountain so constructed that a small stream of water may be 
directed into the back part of the mouth without the drinker having 
a chance to touch the little spout with his lips. This might easily 
be effected by converting the scuttle-butt into a cylinder provided at 
intervals on its circumference with several cup-shaped depressions, 
from the bottom of each of which a small stream of water is forced out 
by gravity and which could be regulated by a sort of spring-lock. 
While the rim of the depression might touch the face of the drinker, 
the cup-shaped depression ought to be made deep enough so that the 
lips could not touch the nipple of the spout. In order to catch the 
small amount of water that is spilt in the operation, a circular trough 
connected with a soil-pipe could be placed below the fountain. 

VENTILATION. . 

Ventilation may be either natural or artificial. In nature, wind- 
currents are created by temperature differences. High temperatures 
over any point on the earth's surface cause the atmosphere to expand 
and, consequently, to rise; low temperatures have the opposite effect. 
A current is caused, therefore, proceeding from centres of low towards 
centres of high temperatures. We speak of ventilation as being 
natural, whenever air-currents are created by atmospheric tempera- 
ture differences alone; ventilation becomes artificial whenever these 



VENTILATION. 339 

natural currents are assisted by other physical or mechanical agencies. 

The ventilation which is constantly taking place in our houses 
and dwellings may be taken as an example of natural ventilation. 
The porous nature of the building materials, the winds, the differences 
between the temperatures of the inside and outside air, are the effi- 
cient causes of this ventilation. In an experiment by von Petten- 
kofer it was found that in a room of 75 cubic metres capacity, one 
complete change of air occurred in one hour through a difference in 
temperature between inside and outside of 20° C. Under ordinary 
conditions, the cold air will enter below and the warmer air will 
make its escape from the top of the building. 

Such natural ventilation, it will readily be seen, could never be 
expected to occur in a ship. A ship's bottom and sides are practically 
made both air- and water- tight. Hence, whatever fresh air is ex- 
pected to get into a vessel must come from the top side and be made 
to find its way to all the various parts below before it can be said that 
the ship is at all ventilated. Since, moreover, a ship is divided into 
many separate compartments not in direct communication with the 
general ship's spaces, the air (the deeper it descends the warmer it 
must get) will be returned before it reaches the deepest parts of the 
ship; it thus must happen that a large portion of the inside of a 
ship will never be ventilated by natural means at all. This is also 
the reason why the air in ships is always found to be growing more 
and more contaminated, the deeper down towards the bottom it is 
examined. We may now also understand why it is that, in order to 
ventilate all ships effectively, we must resort to ventilation by arti- 
ficial means. 

Since the most economical, thorough, and efficient ventilation is 
that ventilation which aids the natural currents existing inside of a 
vessel, all artificial systems should be so arranged as to meet this 
most important requirement. In a steamer, for instance, of modern 
construction, such as a cruiser or battleship, with enormous fires and 
engine-rooms, large steam-pipes, and a number of auxiliary engines 
situated, for the most part, in the middle of the ship's space and 
radiating considerable amounts of heat, air-currents from all parts of 
a vessel would, under average conditions, move in their direction; 
that is, from the colder, lower, and peripheral portions toward the 
warmer, higher, and central parts of the compartments. All supply 
shafts in a ship, in accordance with this principle, should, therefore, 
be made to reach as nearly as possible the bottom and the most periph- 
eral parts of any compartment to be ventilated, before being allowed 



340 TEXT-BOOK OF HYGIENE. 

to sot free the imprisoned air which they brought down from above 
and which is intended for the ventilation of any particular compart- 
ment ; while the outlets for the foul air should, for the same reasons, 
be nearest tiie middle line and open flush with the deck ceiling. It 
is in this manner only that any compartment can be most efficiently, 
as well as most economically, ventilated. 

Different Methods of Ventilation. — A ship is said to be ventilated 
either by the vacuum or the plenum method, according as the greater 
motive power is in the discharge or in the supply part of the system. 
The power may be solely in either one or the other of the two parts, 
or it may be shared between them. Its predominance in the one or 
the other determines the "vacuum" or the "plenum" character of 
the system. (Woodbridge.) 

Vacuum Method. — This method causes a current of air in an 
enclosure by a partial vacuum within it. Into such an enclosure the 
air then flows through every available channel, both provided and ac- 
cidental. From whatever points, therefore, the pressure may be 
greater than in the enclosure ventilated by the vacuum method, from 
thence it will move toward that enclosure. Each space, therefore, is 
more or less at the mercy of its surroundings and of conditions be- 
yond the control of its occupants. The vacuum method of ventila- 
tion on shipboard puts the breather at the point of discharge of foul 
air, and sends into the living spaces specimens of air from every part, 
near or remote, whether filled with pure or foul air. 

Plenum Method. — This method, by putting each compartment 
under slight pressure, prevents leakage of air from adjoining com- 
partments. It tends to accelerate the escape of foul air through 
natural outlets, and gives the occupants control over the source and 
the velocity of their air-supply. The method puts the breather at 
the point of supply and, consequently, in a position to breathe the 
best of air. It is recommended as the best by Eubner, Kirchner, Karl 
Schmidt, Notter, Harrington, Woodbridge, and Munson. It will 
supply a steady current of fresh air to all the compartments in a 
ship alike, and by tending to produce even conditions of temperature 
and pressure it will prevent untoward currents and countercurrents 
between the different enclosures, in spite of free communication exist- 
ing between them. 

The ideal aim of any ventilating system, in theory at least, would 
be the getting rid of foul air in an enclosure and the replacing of 
this by fresh air, without the two becoming mixed. In practice, 
however, and as Paibner has long since pointed out, we are obliged 



VENTILATION. 341 

to take our air for inspiration out of the same reservoir into which 
we send our expiratory air. It would, therefore, seem impossible 
for any ventilating system to so sharply separate the good air from 
the foul air as to prevent the two from becoming mixed to a certain 
extent. All artificial ventilation must, accordingly, proceed after the 
manner of a process of dilution, and be so arranged as to keep the 
enclosed air from reaching a composition very much different from 
outside air. This is more especially the case on board all ships, naval 
as well as mercantile, under just such conditions when ventilation 
comes into play most beneficiently, namety, during maneuvres and in 
bad weather. It is, consequently, far more important to provide means 
for an abundant supply of fresh air in the ventilating of ships than 
it is to provide those for getting rid of foul air. The more general 
introduction of the plenum system in ships' ventilation is, therefore, 
most desirable, as well as in the most perfect keeping with the re- 
quirements. 

Since the details of ship ventilation and the principles of the 
examination of air, as well as the sources of its contamination, have 
been very recently discussed by Beyer and Plumert, we may conclude 
this chapter by giving a description of the type plans for the ventila- 
tion of some of our newest designs of battleships. 

But before giving this description, mention must be made of an 
important discovery as regards the composition of the air enclosed in 
the double bottoms, by Dr. C. M. Belli. It had been known for a 
long time that the air in these places became after a time so bad that 
it was dangerous to enter them, without testing the air first by means 
of a candle, and whenever that went out the air in them was renewed 
with a portable ventilator. It was always believed that the cause of 
the asphyxia was an accumulation of C0 2 in these places. 

Belli, on the contrary, found, by a number of eudiometric analyses 
of specimens of air collected from these double bottoms, that while 
the C0 2 was present in the proportion of 1.4 per cent., the oxygen 
had decreased from 20 to 3 per cent. Hence it would seem that all 
previous cases of asphyxia reported as occurring in the double bot- 
toms were due to a want of oxygen rather than to the presence of too 
much C0 2 . Further experiments showed that the oxygen was indeed 
absorbed by the linseed oil and minium, a mixture with which the 
iron sides and bottoms of these compartments are thickly coated. It 
would not be surprising if it should be found, on further experi- 
mentation, that a want of oxygen more than the accumulation of C0 2 
was, after all, the real cause of the insufferable condition of the 



342 TEXT-BOOK OF HYGIENE. 

atmosphere of places in ships other than the double bottoms. Ex- 
perimental inquiries alone can establish the truth of this supposition. 

The Ventilating System of the Idaho and Mississippi. — The 
Ida ho and Mississippi are sister ships and classified as first-class sea- 
going and coast-line battleships. Their length and breadth, at load 
water-line, are 375 and 77 feet respectively. The displacement is 
13,000 tons. They have a bridge deck, upper deck, main deck, berth 
or protective deck, and an upper and lower platform. They will each 
carry a complement of not less than 720 officers and men. 

According to the designs of these vessels, it is the intention to 
provide artificial ventilation for all quarters, living spaces, passages, 
store-rooms, and magazines below the main deck, as well as for the 
air-spaces over the boiler- and engine- rooms and around magazines; 
for the water-closets and similar enclosures above the main deck and 
for turrets. The hull-ventilating arrangements for these vessels were 
designed in accordance with what are considered the latest approved 
methods, the efficiency of which was demonstrated by numerous ex- 
periments. The system has been so subdivided as to render unneces- 
sary the piercing of any of the principal water-tight bulkheads with 
the ducts except where shown in the type plans (Figs. 36, 37, and 38). 

These vessels, having a system of hatches and skylights opening 
through the various decks in nearly vertical lines, in a number of the 
principal subdivisions, it was not considered necessary to install both 
"supply" and "exhaust" systems for any spaces except the dynamo- 
rooms. The main hull ventilation will therefore, be fitted as shown 
in the type plans (see Figs. 36, 37, and 38) with the single-way sys- 
tem. The water-closets, etc., on the main deck will be ventilated on 
the "exhaust" system and the remaining compartments, except the 
dynamo-rooms, on the "supply" or "plenum" system only. 

The ducts are designed to pass the number of cubic feet of air 
per minute through each terminal as may be seen on the type plans 
(see Figs. 36, 37, and 38), or to equal the total number of cubic 
feet per minute for each compartment as marked on the plans, with 
the fans running at a speed corresponding to 1 ounce pressure with 
restricted delivery. This will allow the air to be renewed in the vari- 
ous spaces approximately as follows: — 

1. Officers' quarters and crew space, berth deck outside of trans- 
verse armor, in about twelve minutes, or four times in one hour. 

2. Officers' quarters, crew space, and general work-shop, within 
transverse armor, in about five minutes, or twelve times in an hour. 

3. Water-closets and crew's head in about five minutes. 




■SEC r/OA/ A A 



Fio-s. 40. 41. 42. — Plans showing Arrange 







£>/$f>e/v.s/f/i y 



t of Ventilation on the Idaho and Mississippi. 



VENTILATION. 343 

4. Store-rooms in general, magazines, and passages in about 
eight minutes. 

5. Engine-rooms and steering compartments in about two 
minutes. 

6. Evaporator-rooms in about two and a half minutes. 

7. Air-space over boilers in about one minute. 

8. Dynamo-rooms in about three-quarters of a minute. 
Twenty-three fans are required for the ventilating system of these 

vessels, all to be electrically driven and to be located as indicated on 
the plans (see Figs. 36, 37, and 38). 

Fan No. 1. — To exhaust from water-closets, etc., on the main 
deck forward of bulkhead No. 15, and also from sick-bay water- 
closet and contagious ward. 

Fans Nos. 2 and 3. — To exhaust from firemen's wash-rooms, 
evaporator-rooms, and passages on berth deck, between bulkheads 
35% and 57. The discharges from these fans to be used for ventilat- 
ing the air-spaces over boilers. 

Fan No. 4. — To exhaust from officers' water-closets on main deck 
between bulkheads 52% and 59. The discharge to be used to assist 
exhaust from after dynamo-room. 

Fans Nos. 5 and 6. — To supply fresh air to officers' quarters and 
to compartments above protective deck abaft bulkhead 57. 

Fans Nos. 7 and 8. — To supply fresh air to magazines and store- 
rooms below protective deck, between bulkheads Nos. 67% and 79, and 
also to ammunition passages aft of frame 48. 

Fan No. 9. — To supply fresh air to sick-bay, operating room, 
dispensary, store-rooms, and passages above protective deck and for- 
ward of bulkhead No. 19 ; and also to all compartments below pro- 
tective deck and forward of bulkhead No. 19, except chain lockers 
and trimming tanks. 

Fans Nos. 10 and 11. — To supply fresh air to magazine and 
store-rooms below protective deck, between bulkheads Nos. 19 and 30. 

Fans Nos. 12 and 13. — To supply fresh air to compartments on 
berth deck between bulkheads Nos. 19 and 35% and to ammunition 
passages between frames 30 and 48 ; also to communication room, and 
forward distribution board-room. 

Fans Nos. 14 and 15. — To supply fresh air to forward dynamo- 
room. 

Fans Nos. 16 and 17. — To exhaust from compartment between 
bulkheads Nos. 30 and 35% on berth deck, the discharge to be used 
to assist exhaust from the forward dynamo-room. 



344 TEXT-BOOK OV HYGIENE. 

Fans Xos. 18 and 19. — To supply fresh air to after dynamo-room 
and after distribution board-room. 

Fans No. 80 ami 81. — To supply fresh air to engine-rooms. 

Fans Nos. 82 and 83. — To supply fresh air to steering com- 
partments and store-rooms on upper platform aft of bulkhead No. 
^!»: also to hold between bulkheads Xos. 79 and 83. 

It is the intention to supply all these fans with power sufficient 
to run them continuously, when necessary, at a speed required to 
produce l 1 ^ ounces pressure, under conditions of shop test, but to 
have such variation in speed as will permit them to run under or- 
dinary service conditions at the speed required to produce 1 ounce 
pressure. 

In designing the ventilating system for these ships, great care has 
been taken to allow for the loss of capacity due to frictional resist- 
ance, and special attention was paid to the bends in the ducts, none 
of which are to be made with a radius of throat smaller than the 
diameter of the duct. It was found by experiment that the loss due 
to friction in a twenty-foot length of straight duct is about 10 per 
cent., and that the loss in a ninety-degree bend, when properly con- 
structed, with a radius of throat not less than the diameter of the 
duct, is about the same amount. If the bends are made with a sharp 
joint or with a smaller radius, the loss will be greater. The ducts 
are to be made smooth inside and free from all internal projecting lips 
and other obstructions. The branches and terminals will be made to 
leave the main duct at an angle of not more than 15 degrees to the 
direction of the air-current and be curved to the desired direction by 
a very easy bend. All magazine terminals will be fitted with automatic 
ball attachment and cage, protected by portable one-half inch wire 
mesh covering the same. McCreery or other equally effective adjust- 
able elbows, fitted with butterfly dampers, will be used for terminals 
in all quarters, living spaces, and elsewhere, as shown in type plans 
(Figs. 36, 37, and 38). All the openings of these elbows are to be 
fitted with portable wire mesh, not less than one-half inch. All other 
terminals to be stationary and, except those ending in valves, to be 
fitted with plain butterfly dampers and portable iron mesh, not less 
than one-quarter inch. All terminals to be bell-mouthed to twice their 
area, where fitted with wire mesh. 



Table LIII. 

Tabulated Index to Artificial Ventilation Arrangements of u Idaho 
" Mississippi," Shoionin Part in Figs 36, 37, and 38. 



and 



FAN 


SPACE 


"3 


v 3 

Ph a 






V Pn 3 


.2 S a 






aA5 


-° t* 2 






H^S 


3 0> ^ 

o c < 


Exhaust 


Crew's head, over water-closets 


6 


800 


No. 1 — Main deck 


14 " urinals 


6 


450 


Capacity, 1725 cubic feet per 


11 " wash-basins 


6 


300 


minute 


Contagious ward 


6 


100 


1 oz. pressure 


Sick bay bath-room 


6 


75 


Exhaust 


Exhaust from firemen's wash-room 






No. 2— Main deck 


and supply to air-space over boilers 


1 


3070 


Capacity, 3070 cubic feet 








Exhaust 


Exhaust from firemen's wash-room 


1 


1270 


No. 3 — Main deck 


" dynamo-room and 






Capacity, 3070 cubic feet 


supply to air-space over boilers 


1 


1800 


Exhaust 


From officers' bath and water-closet 


4 


943 


No. 4 — Upper deck 


space 






Capacity, 943 cubic feet 








Supply 


Captain's after-cabin 


10 


160 


No. 5 — Main deck 


" dining-cabin 


10 


200 


Capacity, 4640 cubic feet 


' * state-room 


10 


125 




' ' bath-room 


10 


75 


No. 6— 


41 office 


10 


100 


4640 cubic feet 


" pantry 


10 


50 




Ward-room Dining-room 


10 


400 




44 state-rooms behind 








armor 


4 


100 




14 state-rooms not behind 








armor 


10 


75 




' ' pantry 


4 


150 




Junior and warrant officers' mess- 








rooms (each) 


4 


400 




Junior and warrant-officers' state- 


V 


H25 

\150 




• rooms ( each ) 




Junior and warrant officers' pan- 








tries (each) ' 


4 


125 




Country in vicinity of officers' 








quarters 


4 


2100 


Supply 


Magazines on upper platform 


8 


2200 


No. 7— 


" " lower " 


8 


1650 


Capacity, 4640 cubic feet 


in hold 


8 


350 




Passages and haudling-rooms 


8 


3150 


No. 8 — 


Storerooms 


8 


1620 


Capacity, 4640 cubic feet 








Supply 


Sick Bay 


3J 


600 


No. 9— Berth deck 


Operating-room 


3* 


125 


Capacity, 5320 cubic feet 


Dispensary 


3l 


75 




Lamp-room 


8 


125 




Paints and oils 


8 


200 




Torpedo manipulating-room 


8 


1600 




Fresh water tank space 


8 


200 



(345) 



Table LIIL— {Continued.) 

Tabulated Index to Artificial Ventilation Arrangements of "Idaho" and 
"Mississippi," Shown in Part in Figs. S6, 37 } and 38. 



FAN 


SPACE 


£ 

o » £ 

©« 3 

Si.2 


Cubic Feet 
Per Minute 
About 


Supply 
No. 10— 
Capacity, 3690 cubic feet 

No. 11— 
Capacity, 3690 cubic feet 


Magazines on upper platform 
11 on lower 4< 
■• in hold 

Passages and handling-room 

Store-rooms 


8 ' 

8 

8 

8 

8 


1850 
1720 
1080 
1200 
940 


Supply 
No. 12— Berth deck 
Capacity, 3070 cubic feet 

No. 13— 

Capacity, 3070 cubic feet 


Bakery 

Workshop 

Chief petty officers' quarters 

" " l< wash-room 
Crew space, berth deck 
Ice machine room 
Ammunition passages 
Passages 

Communication-room 
Laundry 


8 
5 
5 
5 
5 
5 
8 
8 
8 
5 


150 
330 

500 

90 

400 

100 

2170 

1300 

80 

300 


Supply 
No. 14— Berth deck 

Capacity, 5320 cubic feet 

No. 15— 
Capacity, 5320 cubic feet 


To forward dynamo-room 


f 


10,640 


Exhaust 
No. 16— Berth Deck 
Capacity, 943 cubic feet 

No. 17— 
Capacity, 943 cubic feet 


Crew space 


8 


1886 


Supply 
No. 18— Berth deck 
Capacity, 5320 cubic feet 

No. 19— 
Capacity, 5320 cubic feet 


To after dynamo-room 


f 


10,640 


Supply 
No. 20— 
Capacity, 10,800 cubic feet 

No. 21— 
Capacity, 10,800 cubic feet 


To engine-rooms 


2 


21,600 


Supply 
No. 22— 
Capacity, 1190 cubic feet 

No 23— 

Capacity, 1190 cubic feet 


To steering gear 
Storerooms 


2 

8 


1615 
765 


Supply 
Two in each boiler room 
each 15,625 cubic feet. 


Each boiler-room 




31,250 



(340) 



QUESTIONS TO CHAPTER XI. 



MARINE HYGIENE. 

Define marine hygiene. In what respects does it differ from naval 
hygiene? What are the causes of the decrease in morbidity and mortality 
in modern ships as contrasted with those in the old ships? What is the mor- 
tality rate among seafaring people in recent times? Name some of the most 
prevalent diseases. 

On what system is a ship drained? What are the separate functions of 
the main, secondary and auxiliary drains, respectively? How is the bilge 
formed? Where is the bilge-room located? What changes in the construction 
of ships have affected the location of the bilge space and how? How is the 
composition of the bilge affected by these changes? What is a bilge-well? 
What is a Macomb strainer and its object? 

What is the chemical and bacteriological composition of bilge-water? 
How many distinct types of bilge-water may be distinguished on board a 
man-of-war? What are the distinguishing characters in each? What are 
the chances of bacterial infection from infected bilge-waters? 

What are the different decks on a merchant ship called? Name the 
different decks on a battle-ship? What is the location of the engine- and fire- 
room? What and where are the double bottoms? Describe the location of 
the men's quarters. What is the usual cubic air-space per man allowed, (1) 
on merchant ships, and (2) on war-vessels? 

What is the effect of dampness on shipboard on the health of the men? 
How is the bilge-room cleaned? Name some of the special precautions to be 
observed in the disinfection of ships in special cases. Enumerate the most 
necessary disinfecting agents on board, and define the uses of each. Describe 
in detail the process of Nocht and Giemsa for the extermination of rats. 

What is meant by the term "ration" and what is the difference between 
it and an ordinary "bill-of-fare" ? What are the food values per gram of 
proteids, fats, and carbohydrates respectively? What are the relative pro- 
portions in proteids, fats, and carbohydrates to which the composition of a. 
complete meal should correspond? 

Describe the U. S. standard evaporator. What may be the sources of 
contamination in the water distilled by this machine? What are the sub- 
stances occasionally found in such water? What is a reasonable allowance 
per man and per day on board ship? What are the dangers of the scuttle- 
butt cup and how are they to be prevented? 

Give an example of natural ventilation. What is the object of artificial 
ventilation, and how must it be arranged to be most effective as well as 
economical? What are the different methods of artificial ventilation, and 
what does each method do? Which of the two is best adapted to ships? De- 
scribe the main features of the ventilating system of the Idaho and Missis- 
sippi. 

(347) 



CHAPTER XII. 

PRISON HYGIENE. 

Although the frightful mortality which formerly seemed a 
necessary accompaniment of the life of the convict has in the past 
half-century markedly diminished, the death-rate among prisoners is 
still very greatly in excess of that of persons of the same age in a state 
of liberty. 

The observations and labors of John Howard, the self-sacrificing 
philanthropist, and of Elizabeth Fry, directed the attention of legisla- 
tors to the necessity of reform in the conduct of prisons and the treat- 
ment of prisoners. As a consequence of the labors of these reformers, 
the principles of prison discipline have been more fully developed 
during the past forty years by students of social science everywhere, 
and certain propositions have been formulated, which govern, to a 
greater or less degree, legislation upon this subject. These propo- 
sitions are, briefly, as follow: — 

Prisoners must be properly classified according to the nature 
of their crime and the duration of imprisonment. 

The two sexes must be strictly separated, and no opportunity 
given for intermingling while in the prison. 

Female prisoners should have female attendants exclusively. 
Male watchmen or other attendants should not be allowed in the fe- 
male department of a prison. 

All prisoners must be kept employed at some manual labor, not 
necessarily for profit, but as an agency in the moral reformation of 
the convict. 

Punishments for infractions of discipline must not be excessive. 

Efforts should be constantly made tending to the reclamation of 
criminals from their life of sin and crime. 

Due care must be taken by the State to preserve the health and 
life of the prisoner whom the State has deprived of liberty and the 
opportunity of taking care of himself. 

A proper classification of prisoners, according to the degree of 

their criminality, the nature of the crime of which they have been 

convicted, or the length of time for which they have been sentenced, 

is now insisted upon by all students of prison discipline. As this sub- 

(348) 



PRISON HYGIENE. 349 

ject more nearly concerns the social or legal relations of prisoners 
rather than their sanitary interests, it is here passed over with a mere 
mention. 

The separation of the sexes, necessity of female attendants on 
prisoners of the same sex, employment of prisoners, and moral re- 
formation of criminals likewise belong especially to the social aspects 
of the question, and can find no discussion in this place. 

Eegarding the remaining proposition, however, that which de- 
mands that the State shall exercise due care over the prisoner's health, 
it comprises a question that demands consideration in a text-book of 
hygiene. 

There is now a general concurrence of opinion that the State, in 
depriving any person of liberty, has no right to subject the individual 
suffering such deprivation to any danger of disease or death. In 
other words, the State has no right to abbreviate the life of the convict 
sentenced to prison. This proposition requires that the State see to 
it that the prisoner is well fed, well clothed, and well housed ; that he 
shall be well cared for when sick, and that when his term of imprison- 
ment expires he shall be set at liberty, with only such effect upon his 
normal expectation of life as would result from the ordinary wear 
and tear of life upon his health. 

It must be confessed, however, that the State is very far short 
of attaining this object. The mortality of convicts, even in the best- 
regulated prisons, where especial attention is paid to the sanitary re- 
quirements of such buildings, is three times as great as among work- 
men in mines, confessedly one of the most dangerous occupations. If 
insurance companies desired to insure the lives of prisoners, the com- 
panies would be obliged, in order to secure themselves against loss, 
to make the premium equivalent to an advance in age of twenty 
years. This means that a free person has as long expectation of life 
at 40 years as a prisoner has at 20. Attention is again called to the 
fact that the conditions in the most favorably situated and liberally 
managed prisons only are here considered. What the results are in 
other institutions, less favorably constructed and managed, will be 
apparent from the following brief statement : Mr. George W. Cable 1 
has shown that in some of the prisons in the Southern States, under 
the vicious lease system, the mortality is eight to ten times greater 
than in properly constructed and managed prisons elsewhere. In 
Louisiana, for example, 14 per cent, of all the prisoners died in 1881 ; 
• 

1 Century Magazine, February, 1884. 



350 TEXT-BOOK OF HYGIENE. 

and in the convict wood-cutting camps of the State of Texas one-half 
of the average number so employed during 1879 and 1880 died. 

The mortality of prisoners is greatest in the second, third, and 
fourth year of their confinement. In Millbank Prison, in England, 
the death-rate per 1000 was 3.05 in the first year, 35.64 in the sec- 
ond, 52.26 in the third, 57.13 in the fourth, and 44.17 in the fifth 
years of imprisonment. 

The diseases most frequent among prisoners are pulmonary 
phthisis and diseases of inanition, manifested by general dropsy. 
Consumption furnishes from 40 to 80 per cent, of all deaths. When 
prisoners are attacked by acute febrile or epidemic diseases (small-pox, 
cholera, dysentery), the mortality is much higher than among per- 
sons in a state of liberty. This fatality is due to an anemic or 
cachectic condition, which has been called "the prison cachexia," — a 
depravement of constitution which yields readily to the invasion of 
acute diseases. Recently a number of model prisons have introduced 
modern sanatorium treatment of consumptive prisoners. 

Prisons should be built upon a healthy site, be properly heated 
and ventilated, have an abundant water-supply, and be supplied with 
facilities for a prompt and thorough removal of sewage. Baths and 
lavatories should be conveniently arranged in order that thorough 
cleanliness can be enforced. 

The problem of feeding prisoners requires careful study. The 
food should not only be sufficient in quantity and of good quality, 
but it should be well cooked, and the bill-of-fare varied often in order 
to avoid creating a disgust by an everlasting sameness. Prisoners 
often suffer from nausea and other digestive derangements, brought on 
solely by the monotonous character of the daily food. 

In workshops and sleeping-rooms, dormitories or cells, the cubic 
air-space allowed to each inmate should not be less than 17 cubic 
metres, with proper provision for ventilation. The use of dark or 
damp cells as places of confinement is a relic of the barbarism in the 
treatment of convicts against which John Howard raised his voice so 
effectively in the last century. An abundance of sun-light should be 
admitted into every room in which a human being is confined. 

An important hygienic measure is daily exercise in the open air. 
It should be regularly enforced, and its modes frequently varied in 
order that it may not degenerate into a mere perfunctory performance. 

Punishment for infractions of the prison discipline should be in- 
flicted without manifestation of passion, and only under the im- 
mediate direction of some official responsible to the State. It is ques- 



PRISON HYGIENE. 351 

tionable whether physical punishments, such as whipping, tricing up 
by the thumbs with the toes just touching the floor, bucking and 
gagging, and similar barbarities should be permitted under any con- 
ditions. The permission to exercise such power is extremely liable 
to be abused by officials. The system of leasing out prisoners to pri- 
vate parties which prevails in some of the southern United States 
is vicious in the extreme, because it places the convict under the con- 
trol of persons not responsible to the State, and, in the majority of 
instances, morally unfitted to wield the power of inflicting punish- 
ment. 



QUESTIONS TO CHAPTER XII. 

PRISON HYGIENE. 

How does the mortality of those who are in prison compare with those 
of the same age who are free? What philanthropists called early attention 
to the abuses of prisons and prisoners? What fundamental propositions now 
practically govern prison legislation? Why must the State exercise due care 
over the prisoner's health? What must the State do to attain this object? 
Does it succeed in doing it? How does the excessive mortality compare with 
that of dangerous occupations? How does the expectation of life compare 
with that of those outside of prison? What is the mortality where the lease- 
system obtains? When is the mortality among prisoners greatest? What 
diseases are most frequent among prisoners? What is the effect of acute 
febrile or epidemic diseases upon prisoners? To what is this due? 

What principles should be observed in prison construction? What points 
should be particularly observed regarding the food of prisoners ? How much 
air-space should be allotted to each prisoner, whether in workshops or cells? 
What precautions should be taken against dampness and absence of sunlight? 
What is another important measure that should be enforced daily? How 
should all punishments be inflicted, and what ones should be prohibited? 
What can be said of the lease system? 



(352) 






CHAPTER XIII. 

PERSONAL HYGIENE. 

All sanitary and hygienic precautions relate more or less directly 
to the person, but those principles which concern most intimately 
the habits and body of the individual, rather than his surroundings 
and environment, are conveniently grouped in a class denominated 
Personal Hygiene. 

EXERCISE AND TRAINING. 

Exercise is the performance of work, or overcoming resistance. 
To be efficacious from a hygienic standpoint, it must affect not only 
all the voluntary muscles, but every organ and tissue of the body. 

The healthy functions of the bodily organs can only be main- 
tained by more or less constant use. A muscle or other organ that 
is unused soon wastes away, or becomes valueless to its possessor. 
On the other hand, trained use of the various organs makes them more 
effective for the performance of their functions. Thus, by practice, 
the eye can be trained to sharper vision, the ear to distinguish slight 
shades of sound, the voice to express varying emotions, the tactile 
sense to accurately appreciate the most minute variations of surface 
and temperature, and the hand to greater steadiness or the perform- 
ance of difficult and complex feats. The effectiveness of other organs, 
muscles, or groups of muscles can also be increased by systematic 
training, as is seen in the athlete and gymnast. 

When a muscle contracts, the flow of blood through it is in- 
creased. Hence, contraction of a muscle, which consumes or con- 
verts stored-up energy, at the same time draws upon the circulation 
for a new supply of food-material to replace that consumed. The 
activity of the circulation through a muscle in action results in in- 
creased nutrition and growth of the muscle. 

During muscular action the activity of the respiratory process is 
increased. A larger quantity of air is taken into the lungs, more 
oxygen is absorbed by the blood, and an increased elimination of car- 
bon dioxide takes place. The experiments of Pettenkofer and Voit 
show that, while in a state of rest the average absorption of oxygen 
in twelve hours amounted to 708.9 grammes, during work the amount 
reached 954.5 grammes. For the same period the elimination of car- 

23 (353) 



354 TEXT-BOOK OF HYGIENE. 

bonic dioxide was: during rest, 911.5 grammes; during work. 1284.2 
grammes. 

Upon the circulation muscular exercise likewise exerts a manifest 
influence. The action of the heart is increased both in force and fre- 
quency, the arteries dilate, and the blood is sent coursing through the 
system more rapidly than when the body is at rest. 

Cutaneous transpiration is also promoted by muscular exercise. 
In this way some of the effete matters in the system are removed, being 
held in solution and carried through the skin in the perspiration, 
helping out the kidneys in the performance of their function, and 
saving them from undue wear and tear. 

There can be no question that systematic training of the mus- 
cles has a favorable influence upon health and longevity. Persons 
who are actively engaged in physical labor, other things being equal, 
are healthier, happier, and live longer than those whose occupation 
makes slight demands upon their muscular system. In default of 
an active occupation the latter class is forced, if good health is de- 
sired, to adopt some form of exercise which will call the muscles into 
activity. 

The principal methods of physical training are walking or 
running, rowing, swimming, out-of-door games, such as golf, tennis, 
foot-ball, and base-ball, and the various in-door gymnastic exercises. 
Eapid walking or running is one of the best methods of physical exer- 
cise, for, not only are the muscles of the legs and thighs developed, 
but the capacity of the chest is increased — one of the principal objects 
of physical training. By combining walking with some form of 
in-door gymnastics, such as practice with dumb-bells, Indian clubs, 
rowing-machines, or pulley-weights, nearly all the good effects of the 
most elaborate system of training can be obtained. 

For the gymnastic exercises various forms of useful labor may 
be substituted with advantage, such as wood-chopping or sawing, or 
moderate work at any physical labor. 

The scheme of studies in our public-school system should include 
physical training for both sexes. This is a question not merely of 
individual, but of national importance. Weak and unhealthy chil- 
dren are not likely to grow up into strong and healthy men and 
women ; and the latter are necessary for the perpetuity of the nation. 
The time seems to have arrived when physical education should no 
longer be looked upon as a whim of unpractical enthusiasts and hobby- 
riders, but as an indispensable element in every school curriculum. 

There is a tendency among instructors in physical training to 



EXERCISE AND TRAINING. 



355 



make their systems too complicated, or dependent upon expensive or 
cumbersome apparatus. This is to be deprecated. All the muscles 
of the body can be called into action by very simple exercises, easily 
learned and readily carried out. 

An important preliminary to all methods of training is a thorough 
physical examination of the pupil by a competent physician, in or- 
der to determine whether certain exercises are allowable. For ex- 
ample, in all organic heart affections exercises of a violent character 
must be interdicted. A boy or man with valvular disease of the 
heart cannot run, row, or swim with safety. The organ is easily 
overtasked in this condition and liable to fail in its function. 

One of the simplest and best methods to cause the pupil to as- 
sume a correct position of the body, and to acquire ease and grace in 
his movements, is to teach him the "setting-up," as practiced in the 
United States army. 1 

In walking, a free, swinging step should be acquired, with the 
head erect, shoulders thrown back, and the chest well to the front, the 
whole body from the hips upward inclining slightly forward. The 
clothing should be loose around the upper part of the body, in order 
not to interfere with the freest expansion of the chest, and to give the 
lungs and heart ample room for movement. Even in-door gymnastic 
exercises alone, when practiced under intelligent provision, will ac- 
complish very favorable results, as shown by the following table : — 



Table LIV. 

Showing Average State of Development on Admission to Gymnasium ; Average State 
of Growth and Development after Six Months' Practicing Two Hours a Week, 
and Average Increase During that Time. (Bowdoin College Gymnasium, under 
Dr. D. A. Sargent. Two Hundred Students from the Classes of 1873 to 1877, 
inclusive. Average Age, 18.3 Tears. ) 2 



Height 

Weight 

Chest (inflated) . 
Chest (contracted) 

Forearm 

Upper arm (flexed) 
Shoulders (width) 

Hips 

Thiech 

Calf 



On Admission. 



170.0 cm. 
60.7 kg. 

87.5 cm. 

80.6 " 
25.0 " 
27.5 " 

38.7 " 
78.7 " 
48.7 " 
31.2 " 



After Six 

Months' 

Practice. 



170.6 cm. 
61.6 kg. 
91.8 cm. 

82.4 " 
26.8 " 
29.0 " 

40.5 " 
84.4 u 

52.6 " 
33.0 " 



Average 
Increase. 



0.6 cm. 
900.0 gms. 
4.3 cm. 
1.8 " 
1.8 ik 
1.5 " 

1.8 " 

5.7 " 

3.9 " 

1.8 " 



1 Upton's Infantry Tactics. School of the Soldier, Lesson I. 
2 Apparatus used: Weights, 4500 to 6750 grammes; Dumb-bells, 1125 
grammes; Indian clubs, 1575 grammes; Pulleys. 



356 TEXT-BOOK OF HYGIENE. 

The table on the following page shows the average rate of in- 
crease in development in a two years' and a four years' class in Am- 
herst College, and also the percentage of increase in one four years' 
class from entrance to graduation. The interesting fact has been 
brought out by Mr. Delabarre that tobacco-smoking has a decidedly 
deleterious effect upon the rate and percentage of physical develop- 
ment in students. In weight non-smokers gained 24 per cent, over 
smokers; in height, 37 per cent., and in chest-girth, 42 per cent. 

However necessary for the preservation of health physical exer- 
cise may be, overexertion should be carefully avoided. Overstrain 
and hypertrophy of the heart are often the results of excessive exer- 
tion. Dr. Da Costa has described a form of "irritable" and weak 
heart occurring especially among soldiers, which he has clearly 
traced to overexertion. Severe labor and violent athletic exercises 
have been folloAved by like serious results. Long-distance pedestrian- 
ism has furnished, within recent years, quite a number of individuals 
who were broken down in health by the excessive strain on the physi- 
cal organization involved. Cardiac strain is not infrequent among 
this class. Spasm, paralysis, or atrophy of muscles sometimes results, 
when these are exhausted by uninterrupted or excessive exercise. This 
effect is shown by writers' and telegraphers' cramp, and similar affec- 
tions. For these reasons it is important that exercise both for health 
and for actual work should be so regulated as to conduce to the indi- 
vidual's benefit, and not to his detriment. 

As to the amount of exercise required, Dr. Egbert says (Hygiene 
and Sanitation, p. 283) : "It is hard to determine how much exercise 
any given person ought to take, as the personal equation varies so 
much. The average healthy man should probably do work equivalent 
to 150 foot-tons daily. The work of walking on a level at the rate 
of three miles per hour is said to be equal to that of raising one- 
twentieth of the body-weight through the distance walked. Accord- 
ing to this, a man of 150 pounds in walking one mile does work equal 
to 17.67 foot-tons, and his total daily physical labor should be equiva- 
lent to walking about nine miles at the above rate to get the proper 
amount of daily exercise. This seems like an excessive amount, but 
if the actual physical work of one's customary vocation be taken from 
this, it will not leave so very much for the daily health-task; and 
while the natural disinclination of many to exercise grows stronger 
by indulgence, and while urgent reminders are wanting and the evils 
arising from the neglect, abuse, or misuse of exercise are not so very 
immediate or apparent, the latter are still certain to result, and are 
not at all consistent with good and perfect health." 



BATHS AND BATHING. 



357 



Table LV. 

Showing Physical Gains of Students in Amherst College During a Part and During 
the Whole of the College Course. (Prof E. Hitchcock, Dr. H. H. Seelye, and 
Mr. F.A. Delabarre.) 



Weight 

Height 

{Sternum 

Navel 

Pubes 

Knee 

Sitting 

Girth, Head 

Neck 

Chest repose .... 

Chest full 

Belly 

Hips 

Right thigh . . . . 

Left thigh 

Right knee 

Lett knee 

Right calf 

Lett calf 

Right instep .... 

Left instep 

Upper right arm . . 

U. R. A. contracted 

Upper left arm . . 

Right elbow . . . . 

Lett elbow 

Right forearm . . . 

Left forearm .... 

Right wrist . . . . 

Left wrist 

Breadth, Head 

Neck 

Shoulders 

Nipples ...... 

Waist 

Hips 

Right-shoulder elbow . 
Left-shoulder elbow . . 
Right elbow-tip . . . . 

Left elbow-tip 

Length, Right foot . . 

Left foot 

Stretch of arms . . . . 
Horizontal length . . . 
Strength 

Lungs 

Back 

Chest dip 

Chest pull up . . . 

Legs •• 

Right forearm . . . 

Left forearm . . . 
Capacity of lungs . . . 



Gain of Two 
Years' Class. 



Metric. 



.2.6 
.11 
.3 
.4 
.8 
.4 
.14 
.5 
.10 
.14 
.9 
.10 
.15 
.19 
.13 
.4 
.3 



.2 
.2 
.2 
.2 
.1 
.19 
.14 
..73 
..30 
• 2.8 
b2.6 
bl.l 
• ..33 
a. 5 
».5 
cl.2 



English. 



d5.72 
.43 
.11 
.15 
.31 
.15 
.55 
.19 
.39 
.55 
.35 
.39 
.59 
.74 
.51 
.15 
.11 
.35 
.43 
.07 
.07 
.51 
.43 
.55 
.23 
.23 
.15 
.11 
.03 
.07 
.03 
.07 
.43 
.27 
.07 
.07 
.11 
.07 
.07 
.07 
.07 
.03 
.74 
.55 
d 160.9 
d.66 
d61.7 



d72.7 
dll.O 
dll.O 
«73.2 



Gain of Four 
Years' Class. 



Metric. 



5.40 
.16 
.11 
.9 
.5 
.12 
.18 
.7 
.14 
.41 
.34 
.41 
.36 
.24 
.25 
.6 
.7 
.13 
.10 
.8 
.9 
.13 
.17 
.16 
.6 
.5 
.5 
.6 
.2 
.3 
.3 
.4 
.19 
.13 
.9 
.11 
.4 
.4 
.10 
.6 
.5 
.4 
.24 
.20 
.82 
.64 
.28 
2.3 
1.2 
.37 
.7 
.5 
3.6 



English. 



11.8 
.63 
.43 
.35 
.19 
.47 
.7 
.27 
.55 
1.61 
1.33 
1.61 
1.41 
.94 
.98 
.23 
.27 
.51 
.39 
.31 
.35 
.51 
.66 
.62 
.23 
.19 
.19 
.23 
.07 
.11 
.11 
.15 
.74 
.51 
.35 
.43 
.15 
.15 
.39 
.23 
.19 
.15 
.94 
.78 
180.8 
1.41 
61.7 



81.5 

15.4 

11.0 

219.6 



Per Cent. 

of 

Increase 

in Class 

of '91. 



8.9 

0.6 

0.7 

12 

3.3 

0.4 

1.3 

0.5 

2.5 

3.0 

1.0 

4.1 

2.4 

3.0 

3.1 

0.8 

1.1 

2.8 

2.3 

0.8 

0.8 

6.3 

6.4 

7.8 

3.5 

3.5 

3.3 

3.1 

0.0 

06 

0.6 

1.8 

3.6 

6.4 

3.4 

1.8 

1.1 

0.8 

1.5 

1.5 

1.1 

1.1 

1.3 

0.6 
26.9 
27.8 
24.0 
38.0 
20.5 
26.0 
23.7 
15.6 j 

4.0 



w Jf 



Height, 

2.72 



Girth, 
2.72 



Breadth, 
2.93 



Strength, 
25.31 



Capacity, 
4.00 



A total average gain 
of 5.87 per cent. 



3— Kilos, b— Units. 



c— Litres, d— Pounds, e— Cubic inches, 
and Inches and Tenths. 



All others, Millimetres, 



BATHS AND BATHING. 

The most important sanitary object of bathing is cleanliness. A 
secondary object of the bath is to stimulate the functions of the skin, 



358 TEXT-BOOK OF HYGIENE, 

and to produce a general feeling of exhilaration of the body. Baths 
are used of various temperatures. A cold bath has a temperature of 
from 4° to U° C. (40° to 75° F.) ; a tepid bath from 24° to 30° C. 
(75° to 85° F.) ; a warm bath from 30° to 38° C. (85° to 100° F.) ; 
and a hot bath from 38° to 43° C. (100° to 110° F.). 

Tepid, warm, or hot baths are used principally as cleansing 
agents or as therapeutic measures. They cause dilatation of the cu- 
taneous capillaries, diminish blood-pressure, and reduce nervous 
excitability. The hot bath is also a method of restoring warmth to 
the body in cases of shock, or to remove the immediate effects of 
injurious exposure to low temperature. 

The so-called Eussian and Turkish baths, so popular in the larger 
cities of this country, are modifications of vapor- and hot-air baths, 
or rather combinations of these with cold baths. The Turkish bath 
is especially to be recommended for its depurative and invigorating 
effects. 

Cold baths are used not merely for their cleansing effects, but 
principally for their stimulating effects upon the system. When first 
plunging into a cold bath there is usually a momentary shock; the 
respiration is gasping, and the pulse is increased in frequency. These 
symptoms disappear in a few moments, however, and reaction follows. 
To a healthy person a cold bath is a delightful general stimulant, 
removing the sense of fatigue after physical exertion and causing an 
extremely refreshing sensation throughout the body. 

As a therapeutic measure, the cold bath has a wide field of use- 
fulness. For the reduction of the bodily temperature in fevers and 
inflammatory diseases, and especially in heat-stroke, it is more prompt 
and effective than any other agent at the command of the physician. 

Sea-bathing. — The most stimulating form of the cold bath is 
doubtless the salt-water bath as taken at the sea-shore. The revul- 
sive effect of the impact of the waves and breakers upon the skin and 
the stimulation due to the saline constituents of the sea-water heighten 
the invigorating effects of the simple cold bath. The beneficial results 
of sea-bathing are, however, not entirely due to the bath, but are to 
a great degree dependent upon the bracing air of the sea-shore, absence 
of the care and anxieties of business, and the temporary change in 
food and habits that a residence at the sea-side involves. Neverthe- 
less, salt-water baths are more stimulant to the skin than those of 
simple water, and part of the good effects of sea-bathing can often be 
obtained from a salt-water bath taken at home. The following mix- 



BATHS AND BATHING. 359 

ture of salts dissolved in about 125 litres of water for one bath makes 
a fairly good substitute for a sea-bath : — 

Take of Chloride of sodium (common salt) .... 4 kilogrammes. 
Sulphate of sodium (Glauber's salt) . . 2 

Chloride of calcium % kilogramme. 

Chloride of magnesium l 1 /^ 

There is a prevalent popular belief that it is extremely dangerous 
to enter a cold bath when heated or perspiring. The author is of 
the opinion that this belief is erroneous. The stimulant and brac- 
ing effects of the cold bath are most manifest if it be taken while the 
individual is very warm or bathed in perspiration. Several years ago 
the author made a series of observations upon himself to determine 
the effects of the cold bath when the body was warm. Every afternoon 
a free perspiration was provoked by a brisk walk of about 2 kilo- 
metres in the sun. As soon as the clothing could be cast off, and while 
the body was still freely perspiring, a plunge was taken into a fresh- 
water bath of about 15.5° C. (60° F.). No ill results followed; on 
the contrary, the sensation immediately following the bath, and for 
six or eight hours afterward, was exceedingly pleasant. The health 
remained perfect, and the weight decidedly increased during the two 
months the practice was continued. There is probably no danger to 
a healthy person in this practice, but it is considered advisable to 
immerse the head first ("take a header"), to avoid increasing the 
blood-pressure in the brain too greatly, which might result if the body 
were gradually immersed from the feet upward. 

The following series of rules have been issued by the English 
Royal Humane Society, and are all worth observing by bathers: 
"iWoid bathing within two hours after a meal. Avoid bathing when 
exhausted by fatigue or from any other cause. Avoid bathing when 
the body is cooling after perspiration. Avoid bathing altogether in 
the open air, if, after having been a short time in the water, there 
is a sense of chilliness, with numbness of the hands and feet; but 
bathe when the body is warm, provided no time is lost in getting into 
the water. Avoid chilling the body by sitting or standing undressed 
on the banks or in boats, after having been in the water. Avoid re- 
maining too long in the water, but leave the water immediately if 
there is the slightest feeling of chilliness. The vigorous and strong 
may bathe early in the morning on an empty stomach. The young, 
and those who are weak, had better bathe two or three hours after a 
meal; the best time for such is from two to three hours after break- 



30)0 TEXT-BOOK OF HYGIENE. 

fast. Those who are subject to giddiness or faintness, or suffer from 
palpitation or other sense of discomfort at the heart, should not bathe 
without first consulting their medical adviser." 

To these instructions may properly be added that a warm or 
hot bath should be avoided if the person is liable to exposure to cold 
within a few hours after the bath; that women should, as a ru'e. 
not take a cold bath while menstruating, or during the last two months 
of pregnancy; and that persons suffering from organic heart disease 
should especially avoid surf-bathing. 

After bathing the body should be thoroughly dried with soft 
towels, otherwise eczematous eruptions are liable to follow in the 
parts subject to friction from opposing surfaces of the skin, as in the 
groins, the perineum and inner surface of the thighs, the armpits, 
or the under surface of the breasts in women in whom these organs 
are large and pendant. 

Friction of the skin with a coarse towel, or so-called "flesh- 
brush," is a popular practice, but is not to be universally commended. 
The hyperemia of the surface thus produced may sometimes induce 
cutaneous diseases (erythema, eczema, psoriasis) in those predisposed. 

One of the most serious dangers of cold bathing, but which is 
not sufficiently appreciated, is the tendency to nausea and vomiting if 
the stomach contains much food. There can be no doubt that many 
cases that are called "cramp," and which frequently result in drown- 
ing, are due to this cause. 3 

Cramps of the various muscles sometimes occur, rendering the 
bather helpless, and if in deep water he is liable to drown before as- 
sistance can reach him. 

In drowning death takes place by asphyxia. The respiration is 
arrested by the submersion of the head, the carbonized blood gradually 
poisons the system, and the heart ceases to beat. So long as the heart 
will react to its appropriate stimulus the person may be restored to 
life. The first thing to do, therefore, after a recently- drowned per- 
son is taken out of the water, is to attempt to re-establish the arrested 
respiration. Several methods are in use for this purpose. Sylvester's 
is one of the simplest. It is as follows: — 

The body being placed on the back (either on a flat surface or, 
better, on a plane inclined a little from the feet upward), a firm 
cushion or similar support (a coat rolled up wi'l answer) should be 
placed under the shoulders, the head being kept in a line with the 

3 So far as the author is aware. Dr. John Morris, of Baltimore, first 
called especial attention to this source of danger. 



BATHS AND BATHING. 361 

trunk. The tongue should be drawn forward to raise the epiglottis 
and uncover the windpipe. The arms should be grasped just above the 
elbows and drawn upward until the}' nearly meet above the head, and 
then at once lowered and replaced at the side. This should be imme- 
diately followed by pressure with both hands upon the belly, just 
below the breastbone. The process is to be repeated fifteen to eighteen 
times a minute. 

Several years since the Michigan State Board of Health published 
a method which is comprehensive, effective, easily understood, and 
readily carried out. This method has also been adopted by the United 
States Life-Saving Service. The following are the details of the 
Michigan method: — 

Rule 1. — Eemove all the obstructions to breathing. Instantly 
loosen or cut apart all neck- and waist- bands; turn the patient on 
his face, with the head down hill; stand astride the hips with your 
face toward his head, and, locking your fingers together under his 
belly, raise the body as high as you can without lifting the forehead 
off the ground, and give the body a smart jerk to remove mucus from 
the throat and water from the windpipe, hold the body suspended long 
enough to slowly count one — two — three — four — five, repeating the 
jerk more gently two or three times. 

Rule 2. — Place the patient on the ground face downward, and, 
maintaining all the while your position astride the body, grasp the 
points of the shoulders by the clothing; or, if the body is naked, 
thrust your fingers into the armpits, clasping your thumbs over the 
points of the shoulders, and raise the chest as high as you can with- 
out lifting the head quite off the ground, and hold it long enough 
to slowly count one — two — three. Eeplace him on the ground with 
his forehead on his flexed arm, the neck straightened out, and the 
mouth and nose free; place your elbows against [the inner surface] 
your knees and your hands upon the sides of his chest over the lower 
ribs, and press downward and inward with increasing force long 
enough to slowly count one — two. Then suddenly let go, grasp the 
shoulders as before, and raise the chest ; then press upon the ribs, etc. 
These alternate movements should be repeated ten or fifteen times a 
minute for an hour, at least, unless breathing is restored sooner. Use 
the same regularity as in natural breathing. 

Rule 3. — After breathing has commenced restore the animal heat. 
Wrap him up in warm blankets, apply bottles of hot water, hot bricks, 
or anything to restore heat. Warm the head nearly as fast as the body 
lest convulsions come on. Rubbing the body with warm cloths or 



362 TEXT-BOOK OF HYGIENE. 

the hands and slapping the fleshy parts may assist to restore warmth 
and the breathing also. 

If the patient can surely swallow, give hot coffee, tea, jniik, or a 
little hot sling. Give epirits sparingly, lest they produce depression. 

Place the patient in a warm bed, and give him plenty of fresh 
air. Keep him quiet. 

Beware! Avoid delay. A moment may turn the scale for life 
or death. Dry ground, shelter, warmth, stimulants, etc., at this 
moment are nothing — artificial breathing is everything — is the one 
remedy — all others are secondary. Do not stop to remove wet cloth- 
ing. Precious time is wasted and the patient may be fatally chilled 
by exposure of the naked body, even in summer. Give all your at- 
tention and efforts to- restore breathing by forcing air into, and out 
of, the lungs. If the breathing has just ceased, a smart slap on the 
face or a vigorous twist of the hair will sometimes start it again, and 
may be tried incidentally. Before natural breathing is fully restored, 
do not let the patient lie on his back unless some person holds the 
tongue forward. The tongue by falling back may close the windpipe 
and cause fatal choking. 

Do not give up too soon; you are working for life. Any time 
within two hours you may be on the very threshold of success without 
there being any sign of it. 4 

In all large cities and towns provision should be made for free 
public baths, conducted under official supervision, and for the especial 
use and benefit of the poorer classes. General cleanliness is not 
merely a factor in the preservation of the public health, but there is 
good reason to believe that the cause of good order and decency would 
likewise be promoted by furnishing the public the means of easily and 
cheaply keeping clean. Many cities in the country have established 
public baths upon an increasingly generous scale, and these are very 
popular and have doubtless been of great benefit. The author has 
?hown 5 that about five-sixths of the inhabitants of the large cities in 
the United States have no facilities for bathing except such as are 
afforded by a pail of water and sponge, or in summer the proximity 
of some body of water easily accessible. The most economical and 
best form of bath for public use would doubtless be the needle or 
rain bath recommended by the author in the paper referred to. Mr. 
W. P. Gerhard has also strongly advocated this form of bath. 



4 Report of Michigan State Board of Health, 1874, pp. 91-99. 

5 Address in State Medicine, Journal American Medical Association, 
July 2, 1887. 



CLOTHING. 363 

It would be well if boards of health and building commissioners 
would issue no permits for dwelling-houses, the plans for which do 
not include proper water-supply and bathing facilities. 

CLOTHING. 

The primary object of clothing is the protection of the body 
against the injurious influences of heat, cold, and moisture. Second- 
arily, the moral sense of civilized communities demands that the nude 
human body shall not be exposed in public. Hence, there are moral 
as well as sanitary reasons for the wearing of clothing ; only the latter 
can be considered in this place. 

Bodies radiate or absorb heat accordingly as they are surrounded 
by a medium having a lower or a higher temperature than themselves. 
In order, therefore, to avoid chilling of the human body if exposed 
to a temperature below 37° C. (98.6° F.), clothing must be worn to 
prevent or retard radiation of the body-heat. Exposure of the un- 
protected body to a low temperature would not only cause chilling 
of the surface owing to the rapid loss of heat, but would incidentally 
produce congestion of internal organs by causing constriction of the 
superficial capillaries. 

Clothing is also worn as a protection against great heat. The 
head, especially, needs protection from the sun's rays. Evidence is 
accumulating to the effect that direct sun-light, if excessive, is equally 
injurious. 

The materials from which clothing is made are, principally, 
cotton, linen, wool, silk, and the skins of animals. Of these, prob- 
ably the most universally used is cotton. It is cheap, durable, does 
not shrink when wet, absorbs little water, and conducts heat readily. 
It is therefore especially valuable for summer garments, allowing 
rapid dissipation of the body-heat and evaporation of the perspiration. 

Linen conducts heat even better than cotton, and is for this 
reason largely used for summer clothing. Its principal advantage 
over cotton is that it is more durable and less harsh to the skin. 

Wool absorbs water readily and is a bad conductor of heat. It 
is therefore valuable as a winter garment, retarding radiation from 
the body. Woolen undergarments should be worn at all seasons, in 
order to prevent too rapid changes of the surface, and so invoking dis- 
eases depending upon chilling of the body. Clothing of pure wool 
(flannels) is liable to irritate the skin of some persons. A mixture of 
wool and cotton, known as "Saxony wool," is softer and less irritating, 
and makes a serviceable substitute for pure wool. 



364 TEXT-BOOK OF HYGIENE. 

Silk is often used for undergarments. It is light, soft, and a 
bad conductor of heat. 

Linen-mesh combines the advantage of both cotton and wool, and 
is an excellent material for undergarments. 

The skins of animals, with the fur on, are often used for outside 
clothing. They furnish great protection against severe cold. The 
skin is impermeable to wind and rain, while the thick, pilous covering 
of fur retards to a very great degree the radiation of heat. In British 
America, the Xorthwestern States and Territories, and in the Arctic 
regions, the use of skin clothing is necessary for comfort. 

As a protection against moisture (rain and snow) rubber cloth is 
used for overcoats, etc., but it is not now so much employed as for- 
merly, because, while it serves effectually in keeping out the rain, it 
prevents evaporation of the perspiration, increasing the liability to 
chill, and rendering the person wearing it very uncomfortable, except 
in cold weather. Outer garments waterproofed after the method 
known as the "Cravenette" process, and made of almost any mate- 
rial desired, are now substituted. 

Leather is used almost exclusively in the manufacture of foot- 
wear. It is sometimes used, however, for other articles of clothing, 
such as coats, trousers, etc. It furnishes most effective protection 
against cold. 

The color of the clothing is of great importance. Exposed to the 
sun, white wool or silk absorb very little more heat than linen or 
cotton, but the same material, of different colors, when exposed to 
the sun's rays, exhibits marked differences in absorptive capacity. 
The following table shows the results of some experiments of Petten- 
kofer. The material used was cotton shirting of the colors named : — 

White absorbed 109 heat units. 

Light Sulphur Yellow absorber! 102 " 

Dark Yellow absorbed 140 " 

Light Green absorbed 155 " 

Turkey Red absorbed 165 " 

Dark Green absorbed 1G8 " 

Light Blue absorbed 198 " 

Black absorbed 208 " 

When protected from the sun's rays, however, the material be- 
comes important and the color is of little consequence. Wool, being 
a bad conductor of heat, retards radiation from the body, and is 
hence the best material for winter clothing. 

Gases and vapors are absorbed by clothing and also disease-germs 



CLOTHING. 365 

may be conveyed from place to place. It has been found that woolen 
clothing possesses this power of absorption to a much greater degree 
than linen or cotton. The bad odor of a crowded room or of tobacco- 
smoke frequently clings to woolen garments for days, although they 
may be exposed constantly to the air during the interval. It would 
be advisable, therefore, that physicians attending infectious diseases, 
hospital attendants and nurses, should wear linen or cotton clothing 
instead of woolen. 

Clothing should be made to fit properly. It should not restrain 
muscular movements, obstruct the circulation, or compress organs. 
Hence, corsets, belts, and garters are to be condemned. It is a fact of 
common observation that moderately loose clothing is warmer than 
close-fitting. 

Especial attention should be given to the shape and fitting of foot- 
wear. Boots and shoes are usually made with little regard to the 
physiological anatomy of the foot, and as a result the feet of most 
Americans are deformed, beauty and usefulness being in a great de- 
gree sacrificed to the Moloch of fashion. 6 

Dyes used for coloring fabrics are sometimes poisonous. The 
author has repeatedly seen troublesome eruptions, and even ulcerations 
of the legs, from wearing stockings dyed with aniline compounds. 

By appropriate treatment clothing can be made non-inflammable. 
Tungstate and phosphate of soda are used to reduce the inflammabil- 
ity of fabrics. The addition of 20 per cent, of tungstate of soda and 3 
per cent, of phosphate of soda to the starch-sizing used for stiffening 
linen is effective. The material is not injured by it, and a smooth sur- 
face and polish can be obtained under the hot iron. Prof. Kedzie 
has recommended borax for the same purpose. He says : "The sim- 
plest and easiest way to make your cotton and linen fabrics safe from 
taking fire is to dissolve a heaped teaspoonful of powdered borax in 
one-half pint of starch solution. It does not injure the fabric, im- 
parts no disagreeable odor, and interferes in no way with the subse- 
quent washing of the goods. It does not prevent the formation of a 
smooth and polished surface in the process of ironing. Borax can be 
found in every village, and is within the reach of all. It is a cheap 
salt, and its use for this purpose is very simple/' 7 



6 See a practical paper by Dr. Benj. Lee, A Shoe That Will Not Pinch, 
in Sanitarian for June, 1884, p. 493. 

'Michigan State Board of Health, p. 181, 1880. 



TEXT-BOOK OF HYGIENE. 



RECREATION AND REST 



Eecreation is not by any means idleness, but a variety of occu- 
pation, and oftentimes is hard physical work. By its means a relaxa- 
tion of both mind and body from the worries and fatigues of one's 
daily avocation may be effected. No rule can be laid down as to the 
exact amount of sleep necessary, for it is a matter of habit, age, and 
temperament. Generally speaking, young persons require more sleep 
than the aged. The most refreshing sleep is supposed to be that taken 
during the early hours of the night, but the habit, where necessary, 
of sleeping any time during the twenty-four hours may be acquired. 
The following simple rules should be observed : — 

Do not eat heavy meals late at night. Have fresh air in the 
sleeping-room the year round, but do not have the bed in a draught. 
Do not sleep with an artificial light burning in the room; it requires 
increased provision for ventilation, and, by shining in the eyes, pro- 
duces inflammatory troubles of the lids. Do not have carpets or 
hangings in the sleeping-room, but let the furniture be of the very 
simplest kind. If two people occupy the same room, they should oc- 
cupy separate beds. Do not sleep in any garments worn during the 
day. Have the night-garments loose and comfortable: warm in 
winter, cool in summer. Have the bed-coverings light but warm, 
remembering that a number of layers makes a warmer covering than 
the same weight of material woven in one piece. Do not sleep on 
feather beds. Sleep with the head low and not with it propped up 
on several pillows, because this interferes with deep breathing, con- 
tracts the chest, and favors stoop shoulders. Lie on the right side 
when you first go to bed ; it hastens food which may be in the stom- 
ach towards the pylorus and aids digestion, favoring natural sleep. 



QUESTIONS TO CHAPTER XIII. 

EXERCISE AND TRAINING. 

What is absolutely necessary for the maintenance of the healthy func- 
tions of the body? What is the effect of disuse upon any organ? Of train- 
ing? 

What occurs when a muscle contracts? What is the result of increased 
activity of circulation in a muscle? What is the effect of muscular action 
on the respiratory process? What is the difference as to the absorption of 
oxygen in a state of rest and during work? As to the elimination of carbon 
dioxide and water? What is the effect of muscular action upon the circu- 
lation? Upon the cutaneous transpiration? 

W T hat is the effect of systematic training upon health and longevity? 
What are some of the principal and best methods of physical training? What 
is one of its most important objects? How may the various methods be com- 
bined with benefit? 

What should be included among the studies and work of all public 
schools? For what purposes? What is the tendency among instructors in 
physical training? Is this necessary, or not? Why? 

What is an important preliminary to all methods of training? Why? 
How may a pupil be taught to assume and maintain a correct position and 
carriage of the body? 

How should a person walk? What attention should be given to the 
clothing worn during exercise? What will be some of the results of sys- 
tematic physical training properly pursued? 

What are some of the results of overexertion ? Does it make a difference 
whether the exercise is too long uninterrupted or whether it is excessive in 
amount and character? 

BATHS AND BATHING. 

What is the most important object of bathing? For what other pur* 
poses may baths be taken? What are the respective temperatures of so-called 
cold, tepid, warm, and hot baths? What are the physiological effects of the 
last three? In what surgical emergencies may the hot bath be used? For 
what are cold baths used? What are their physiological effects? How may 
the cold bath be used therapeutically? 

What is the most stimulating form of cold bath? To what are its 
beneficial effects due? How may a salt-water bath be prepared at home? 
Is there any danger to the healthy in cold bathing while the body is per- 
spiring freely? What precaution should be taken before entering a cold 
bath? What rules may be laid down for bathing in the open air? When 
is the best time for bathing? Who should not bathe without previous medical 
advice? When should hot baths not be taken? What should follow all baths? 

(367) 



368 TEXT-BOOK OF HYGIENE. 

What is one of the most serious dangers of cold bathing? How does 
death take place in drowning? What is the indication that one apparently 
drowned may still be restored to life? Describe Sylvester's method of arti- 
ficial respiration. What is the method adopted by the United States Life- 
Saving Service? What is essential after breathing has been re-established? 
How should spirits be given? How long should efforts to restore respiration 
be continued? What is to be avoided? 

What are some of the arguments in favor of public baths in large 
cities? 

What is the most economical form of bath for public use? 

CLOTHING. 

W T hat is the primary object of clothing? What are some of the sec- 
ondary objects? What are the probable results of exposing the unprotected 
body to low temperature? What part of the body needs special protection 
against heat? 

What are the principal materials from which clothing is made? Which 
of these is most universally used? Why? In what respect is linen superior 
to cotton? Why are cotton and linen not suited for winter wear or cold 
climates? Why are silk and wool better for such uses? Why should wool 
be worn next the skin? What gives silk its value? Why are furs so warm? 
What are some of the objections to the use of rubber clothing? For what 
is leather chiefly used? 

Of what importance is the color of the clothing? What colors absorb 
least and what ones most heat? If protected from the sun's rays, which is 
the most important in the absorption of heat, material or color? 

What deleterious or harmful matters are absorbed or cling to clothing? 
What kinds of clothing have the greatest power of absorption? What pre- 
cautions should those attending cases of infectious diseases observe? 

Why should clothing fit properly? What parts of the clothing should 
not be too tight? What disturbances may result from the wearing of cloth- 
ing that is too tight? How may improperly-dyed clothing create trouble? 
How may clothing be rendered practically non-inflammable? 



CHAPTER XIV. 

DISPOSAL OF THE DEAD. 

When life is extinct in the animal body decomposition begins. 
This may be either putrefactive or non-putrefactive. The difference 
between the two processes has been explained by Liebig. In putre- 
faction of organic matters only the elements of water take part in 
the formation of the new compounds which result, while in non- 
putrefactive decomposition or decay the oxygen of the air always plays 
an important part. Putrefaction can go on under water, while decay 
can only take place when the supply of free oxygen is abundant. 

The prompt removal of the bodies of the dead from the imme- 
diate vicinity of the living is a matter of prime sanitary importance. 
If death results from a contagious or an infectious disease, the neces- 
sity for the removal of the corpse is evident. But, even where there 
is no danger of propagation of infectious disease, the products of 
putrefaction and decay may give rise to serious derangements of 
health if allowed to pollute the air. 

The chief methods of disposal of the dead are burial in the earth, 
entombment in vaults, and cremation. 

INTERMENT. 

The most common method of sepulture is burial in the earth. 
The corpse is usually inclosed in a case (coffin) of wood or metal, and 
buried from 1 to 2 metres deep. Here decomposition sets in, which is 
at first putrefactive and later on non-putrefactive. In the course of 
several years, from five to ten, the entire body, with the exception of 
the bones, has usually disappeared and become converted into a dry 
mold. 

The soil of a burial-ground should be dry and porous, so as to 
be easily permeated by the air. In a sandy or gravelly soil the decay 
of a corpse is much more rapid than in a moist, clayey soil. In the 
latter the bodies more readily undergo putrefaction, or become con- 
verted into a substance termed adipocere. It has been calculated 
that in a gravelly soil the decay of a corpse advances as much in one 
year as it would in sand in one and two-thirds, and in clay in two and 
one-third years. The decay of the dead bodies is dependent upon the 
presence of living vegetable organisms. If the access of free oxygen 

24 (369) 



370 TEXT-BOOK OF HYGIENE. 

is prevented, the bacteria of putrefaction will thrive and cause pu- 
tridity. If, however, the soil is loose, porous, and easily permeable 
by the air, the bacteria of decay will be present and produce their 
characteristic effects. 

The barometric pressure seems to affect the decomposition of 
dead bodies. For example, at the refuge of St. Bernard, in the high 
Alp's, the bodies of those dying are not buried, but exposed to the air, 
where they undergo a drying, shrinking, and mummification instead 
of putrefaction or decay. 

Alternate saturation and drying of the soil promotes the rapidity 
of decay. 

Certain occupations are said to produce changes in the tissues 
which resist decay. Thus, tanners are supposed to resist the final 
changes of the tissues longer than persons of other occupations. 
Shakespeare makes the grave-digger in Hamlet say: "A tanner will 
last you nine years." The corpses of those poisoned by phosphorus, 
arsenic, sulphuric acid, or corrosive sublimate also decay more slowly 
than in cases of infectious diseases. 

All the tissues may be converted into adipocere, but in the large 
majority of cases only the fat and connective-tissues undergo this 
change. 

SUPPOSED DANGERS OF BURIAL=GROUNDS. 

Popular sanitary literature teems with supposed instances of the 
injurious influences of cemeteries upon the health of persons living 
in their vicinity. An unprejudiced consideration of the subject shows, 
however, that there is no trustworthy evidence that any of the gases 
exhaled by decaying or putrefying bodies are injurious to health. The 
air of closed burial-vaults may be dangerous from the large proportion 
of carbon dioxide contained in it, but the other gaseous products of 
decomposition have no deleterious effects. The dangers to health 
from the proximity of cemeteries are doubtless very much exagger- 
ated. Pettenkofer and Erismann have shown that a single large privy- 
vault, containing about 17 cubic metres of excrement, gives off nearly 
as large an amount of putrefactive gases in the course of one year as 
is exhaled by a burial-ground containing 556 decomposing corpses 
in ten years. 

Where bodies are properly buried, and the ground is not over- 
charged by corpses, it is not probable that infectious diseases are pro- 
pagated from interred bodies. There are no facts on record which 
show that such an event has occurred. 



CREMATION. 371 

The dangers of pollution of water by cemeteries have also been 
much overestimated. The purifying power of soil strata, through 
which the water is compelled to percolate before reaching the well 
after becoming charged with the* products of decomposition, is in 
most cases sufficient to remove all deleterious matters. It must be 
admitted, however, that it is not desirable to have a well or other 
source of water-supply in close proximity to a burial-ground. 

Cemeteries should not be located within a city, but must be easily 
accessible. The soil should be dry gravel or sand, with a low ground- 
water level. The graves need not be deeper than 1% metres to the 
top of the coffin. 

ENTOMBMENT IN VAULTS. 

Burial-vaults in churches or in the open air should be discoun- 
tenanced. The gases of decomposition are given off directly to the 
air without the modifying power of the soil, and often constitute a 
nuisance, even if not deleterious to health. Entombment in vaults 
or crypts has not a single favorable circumstance to recommend it. 

CREMATION. 

Within recent years the rapid incineration of the dead in 
properly-constructed furnaces has been frequently recommended. In 
the United States a cremation furnace was built years ago at Washing- 
ton, Pa., by the late Dr. J. C. LeMoine. Among the remains of those 
cremated were those of the late Dr. Samuel D. Gross, the distin- 
guished surgeon. The practice has not gained very many adherents, 
however, although cremation societies have been organized and fur- 
naces built in several of the cities throughout the country. Aside 
from the objections urged by the more conservative classes, who de- 
sire to adhere to the time-honored custom of interment, serious legal 
objections have been brought forward. In cases where poisoning is 
suspected some time after death, the cremation furnace would have 
destroyed every evidence of crime, and conviction of a criminal 
poisoner could not be obtained. 

The real advantages of cremation, such as rapid destruction of 
a corpse, economy of space in keeping the remains, and avoidance of 
pollution of the soil by decaying bodies, and possible pollution of 
air and water, are more than counterbalanced by the expense and the 
medico-legal objection mentioned. From a sanitary point of view, 
cremation is not necessary in this country. A proper regulation of 
cemeteries will prevent any possible dangers to the living from pollu- 
tion of the air, soil, or water by the decaying remains of human beings. 



372 TEXT-BOOK OF HYGIENE. 

INTERMENT ON THE BATTLE-FIELD. 

After battles, the disposal of the bodies of the slain is often a 
serious problem. Naegeli proposes the following method of inter- 
ment : After selecting the place of burial, the sod and layer of humus 
are removed from a sufficiently large surface and thrown to one side. 
The corpses are then laid upon the denuded place, and the layers of 
corpses separated by sand, gravel, or fine brush-wood. A trench is 
then dug around the pile of dead and the soil gained is thrown over 
the corpses until they are covered to a depth of 1 metre, when the 
humus and sod are placed over the whole. This furnishes a dry 
grave in which decay rapidly takes the place of putrefaction, and the 
corpses soon molder away. The same procedure may be followed in 
cases of epidemics where the number of deaths is too great to prop- 
erly bury them in single graves. 

Before leaving this subject it may be well to consider the matter 
of funerals. The pernicious custom of public funerals in cases of 
contagious diseases cannot be too strongly condemned. In fact, pub- 
lic funerals in such cases should not be permitted by the health au- 
thorities. To minimize the danger, the bodies of persons dead of con-. 
tagious diseases should be wrapped in sheets wet with a solution of 
bichloride of mercury (1:500), and the coffin kept securely closed. 
Still more pernicious is the custom of disposing of the clothing and 
other personal property of the dead of contagious diseases by either 
distributing them among friends, donating to the poor, or selling to 
second-hand dealers. Many epidemics of contagious diseases have 
had their origin in this way. There should be a strict law prohibit- 
ing the sale of any article with which the deceased has come in con- 
tact during the last illness, unless such article is thoroughly disin- 
fected. 






QUESTIONS TO CHAPTER XIV. 

DISPOSAL OF THE DEAD. 

What is the difference between putrefactive and non-putrefactive decom- 
position?- Why must the dead be removed from the living? What are the 
chief methods of disposal of the dead? Which is the most common? 

Why should the soil of burial-grounds be dry and porous? Upon what 
is the decay of dead bodies dependent? What is the usual length of time re- 
quired for the decay of a human body? What may affect the length of this 
period? What changes other than decay may the body undergo? 

Is there any evidence that the air from cemeteries is dangerous to 
health? In what way may the air from a closed burial-vault be detrimental? 
Is it probable that infectious disease-germs are disseminated from dead bodies ? 
Is the pollution of water by cemeteries probable? What agents serve to pre- 
vent this? Where should cemeteries be located, however? Why should en- 
tombment in vaults be discountenanced? 

What are the advantages of cremation? What are the objections to 
it? Is it necessary, from a sanitary point of view, in this country? 

How may the bodies of the dead be interred after battles, or in case of 
very fatal epidemics? What are the advantages of this method? 

What precautions should be observed in cases of contagious diseases? 



(373) 



CHAPTER XV. 

THE GERM THEORY OF DISEASE. 

The ruling doctrine in the pathology of the present day is the 
germ theory of disease. Based upon the doctrine of omne vivum ex 
vivo, and supported by strong experimental and clinical evidence, it 
is accepted by the great majority of physicians. Its advocates claim 
that the large class of diseases known as contagious or infectious are 
all due to the presence in the blood or tissues of minute organisms, 
either animal or vegetable. Many other diseases, not at present in- 
cluded in the above class by general pathologists, are also believed, by 
the adherents of the germ theory, to be caused in the same way. 
The following constitutes a brief review of the most prominent facts 
in the history of the doctrine: — 

The doctrine of the vital nature of the contagion of disease — 
the contagium animatum of the older writers — was held in a vague 
way by many of the physicians of the past, but it was not until the 
latter part of the last century that the theory took definite shape. 
In the works of Hufeland, Kircher, and Linne, the idea is expressed 
with more or less directness that the propagation of infectious dis- 
eases depends upon the implantation of minute independent organ- 
isms into or upon the affected individual. This hypothesis was, how- 
ever, first clearly enunciated and defended with great force by Henle 
in 1840. Three years earlier, Cagniard de la Tour and Schwann had 
established a rational basis for the theory by their observations upon 
the yeast-plant and its relation to fermentation. In 1835 Bassi had 
discovered in the bodies of silk-worms affected by muscardine, a dis- 
ease of these insects which proved very destructive, a parasite which 
was soon shown to be the cause of the disease. Within the next few 
years, Tulasne, DeBarrv, and Kuehn proved that certain fungi were 
the causes of the potato-rot and other diseases of plants. Schoenlein, 
Malmsten, and Gruby, between 1840 and 1845, demonstrated that 
those skin diseases of man classed as the tinece were due entirely to 
the action of vegetable parasitic organisms. 

Up to this time the germ theory, as now accepted, had received 
no support from experiments. All the diseases claimed as parasitic 
were purely local; so far as the parasitic nature of the general dis- 
eases was concerned, all was hypothetical. In 1849, 'Guerin Meneville 
(374) 



THE GERM THEORY OF DISE^VSE. 



375 



discovered a corpuscular organism in the blood of silk-worms affected 
by the pebrine, which was later proven by Pasteur to be the true cause 
of this destructive disease. Pollender, in 1855, and Brauell, in 1857, 
found numerous minute rod-like organisms (bacteria) in the blood 
of animals dead from splenic fever or anthrax. In 1863 Davaine in- 
vestigated the subject more fully, and showed beyond doubt that the 
little organisms discovered by Pollender were the true cause of an- 
thrax. The more recent researches of Robert Koch upon the history 
of these bacteria or bacilli of splenic fever have removed all doubt 
of their etiological significance. 



Sarcina (Packet-cocci) 



'•Vr 



Cocci 



Staphylococci 




Diplococci 



Streptococci 



~%w£>= 



Tetracocci 



With 




Ciliated cell -^ /* 



Spider cell 
Diplococcus 



Tetracoccus W^g > i't 



Monococcus 

Centrally situated 
spores 
Clostridia forms 
Knobbed bacteria with 
terminal spores 



/> 



^^•<Sr 



Zobgloea 

Slender bacilli 
Short bacilli 
Bacilli in chains 
Vibrios (spirilla) 

Comma bacilli 
Spirochaetae 



Fig. 43. — Forms of Bacteria. (From Schenk.) 



In 1883 the last-named observer startled the medical world by 
the assertion that consumption or tuberculosis was a disease of 
microbic origin, and dependent upon the presence, in the affected 



370 TEXT-BOOK OF HYGIENE. 

tissues, of an organism which lie named Bacillus tuberculosis. Much 
controversy arose upon this point, but Koch fortified his position so 
strongly with proofs, both experimental and clinical, that it may now 
be regarded as fully demonstrated. Koch has likewise shown (1885) 
that Asiatic cholera is due to a bacterial organism, termed by him 
the "comma bacillus/' from its shape. It is generally regarded by 
bacteriologists, however, to belong to the class of organisms known as 
spirilla, and not to the bacilli. Eberth discovered the bacillus which 
is now generally accepted as the cause of typhoid, in 1880 ; Fehleisen, 
the micrococcus of erysipelas, in 1883 ; Obermeier, the spirillum of 
relapsing fever, in 1868; Schutz and Loftier discovered the bacillus 
of glanders in 1882; Neisser announced the discovery of the micro- 
coccus of gonorrhea in 1879. The bacillus of leprosy was discovered 
by Hansen, in 1879. The micro-organism of malaria (plasmodium 
malaria?) , which is an animal organism, was discovered by Laveran, 
in 1881. This organism is different from the Bacillus malaria? of 
Klebs and Tommasi-Crudeli, which possesses no pathological signifi- 
cance. Pneumonia may also be regarded as a microbic disease, since 
Sternberg, Weichselbaum, and Frankel have shown the constant pres- 
ence of the diplococcus lanceolatus in the sputa in that disease. In 
1884, Nicolaier and Eosenbach proved that tetanus is due to a bacil- 
lus, Bacillus tetani. In the same year Lofner isolated the diphtheria 
bacillus, observed previously by Klebs. In 1892, Canon and Pfeiffer 
discovered the bacillus of influenza, and in 1894, Ycrzin and Kitasato 
independently isolated the bacillus of bubonic plague. 

The careful observations and researches of the investigators 
mentioned, as well as of many others who have worked earnestly in 
this field, have established the germ theory of disease upon a secure 
foundation. For the diseases mentioned the parasitic origin may be 
accepted as fully proven. For a number of others, among which may 
be mentioned small-pox, yellow fever, scarlet fever, typhus fever, 
measles, hydrophobia, etc., the etiological connection between the dis- 
ease and certain hypothetical organisms not yet discovered appears 
highly probable. 

In connection with the germ theory there has arisen of late a 
very important question in its bearing upon preventive medicine. 
This is the value of the so-called protective inoculations against in- 
fectious diseases. The protective influence of vaccination against 
small-pox is firmly established by indubitable evidence. Within re- 
cent years a procedure introduced by Pasteur to protect animals 
against certain fatal infectious diseases, such as splenic fever, fowl- 



THE GERM THEORY OF DISEASE. 377 

cholera, and rabies, has claimed much attention. Pasteur's observa- 
tions were first made upon the disease termed chicken-cholera. He 
found that the blood of the dead fowls, or of those attacked by the 
disease, swarmed with bacteria. Inoculations of healthy fowls with 
this diseased blood, or with the bacteria alone, carefully freed from 
all animal fluids, produced the same disease. The bacteria were there- 
fore assumed to be the cause of the disease. The investigator then 
took a quantity of these bacteria and "cultivated" them through a 
number of generations, using sterilized chicken-broth as a culture 
medium. Fowls inoculated with the result of the last cultivation were 
still attacked by the same symptoms, but in a very miM degree, and 
almost uniformly recovered from the disease. On subsequent inocu- 
lation with infected blood no effect was produced upon the "vaccin- 
ated" fowls, while the same blood introduced into fowls not "pro- 
tected" by the previous inoculation produced its customary fatal effect. 
Pasteur and others repeated these experiments with the organisms 
found in the blood in splenic fever and obtained similar results. In- 
oculations made with emulsions from the desiccated spinal cords of 
animals that died from rabies have also proven protective against this 
disease. These protective inoculations have been made upon large 
numbers of sheep, cattle, and man, with very remarkable success. The 
"protective inoculations" produce an immunity which is more 01 less 
lasting. 

The most important discovery along the lines of immunity was 
made by Behring, in 1892. This observer found that if diphtheria 
bacilli are cultivated in bouillon, for about a week, the medium con- 
tains the toxic substances of the bacilli in solution. The bacilli may 
then be entirely removed by filtration and the clear fluid represents 
the toxin, of which about 0.001 cubic centimetres will kill a guinea- 
pig weighing 250 to 300 grams. If this toxin is injected into an 
animal in gradually increasing doses, neither of which is large enough 
to prove fatal, the animal acquires an immunity to the diphtheria 
toxins, which are the products of the diphtheria bacillus. Now, the 
blood-serum of this immunized animal is capable of neutralizing the 
toxic properties of the diphtheria toxin either in the test-tube or in 
the body of another animal; in other words, the blood-serum con- 
tains antitoxins. 

For practical purposes, a healthy horse is injected with gradually 
increasing doses of toxin, beginning with 0.1 cubic centimetres and 
ending with several doses of 500 cubic centimetres each. At the end of 
about six weeks from five to nine quarts (according to the size of the 



378 TEXT-BOOK OF HYGIENE. 

horse) of blood are withdrawn from the jugular vein, the blood al- 
lowed to coagulate, and the clear serum prepared for the market. 
This serum is the diphtheria antitoxin. This antitoxin, when injected 
into a person suffering from diphtheria, will neutralize all of the 
free toxins circulating in the b'ood, and the outcome of the case de- 
pends entirely on whether, at the time the antitoxin is used, the 
toxin particles are mostly free or combined with the tissue cells. In 
the latter event the antitoxin is powerless to accomplish very much, 
and the issue is fatal. It is for this reason that the modern physi- 
cian employs antitoxin at the earliest possible stage of the disease, so 
as to neutralize the free toxins before they have a chance to combine 
with the cells. For this reason also a small dose of antitoxin, when 
injected into persons exposed to the infection, may prevent the de- 
velopment of the disease. The introduction of antitoxin in the treat- 
ment of diphtheria has reduced the mortality from diphtheria from 
50 to about 10 per cent. 

Tetanus antitoxin, elaborated by Behring and Kitasato, in 1890 ; 
is based on the same principles and prepared very much in the same 
manner, with the exception, of course, that the tetanus bacillus is 
cultivated under anaerobic conditions. From a therapeutic stand- 
point, however, the antitoxic serum is not as useful as in the case of 
diphtheria. The reason given is that by the time the symptoms of 
tetanus develop, the toxin is practically combined entirely with the 
nerve-cells and, therefore, cannot be neutralized. On the other hand, 
when the antitoxin is used at the time the invasion of the bacillus 
occurs, or during the period of incubation, the development of the 
disease may be prevented with absolute certainty. It is this fact that 
led veterinarians to use tetanus antitoxin in every case of suspicious 
wound in a horse, a practice which should be followed by the physi- 
cian in case of any suspicious wound in man. 

The immunity conferred by the use of antitoxins is passive and 
temporary, the body of the patient not participating in its production. 
In the case of other infections which are caused by micro-organisms 
not possessing soluble toxin, the immunization must be active, and 
can only be accomplished artificially by the employment of "vaccines" 
prepared from the bodies of the dead germs. This form of immu- 
nity, which may be caPed "bacterial," depends for its production on 
altogether different forces, namely, the property of the white blood- 
cells to attract and devour bacteria, or, as Metchnikoff termed it, 
"phagocytosis." However, before invading micro-organisms can be 
imbibed by the phagocytes they must be acted upon or prepared by 



THEORIES OF IMMUNITY. 379 

another substance which is present in the blood. This substance, 
whatever its nature, renders the bacteria capable of becoming im- 
bibed by the phagocytes, and has been recently designated by Wright 
and Douglas as "opsonins" (from opsono, I prepare food for). The 
relative power of phagocytosis in the blood of a patient suffering 
from an infection, as compared with the phagocytic power of the 
blood of a healthy individual towards the same germ, is called the 
"opsonic index." 

These, however, are not the only defensive forces. There are no 
doubt a number of other substances in the tissues and fluids of the 
animal organisms which protect the latter against disease, and it is 
the weakening of any or all of them that makes infection possible. 
The subject of immunity is a very wide one, and it is only now that 
we are beginning to understand it. The time will no doubt come 
when every infectious disease will be either prevented or cured by 
stimulating the production of the necessary defensive agents. 

THEORIES OF IMMUNITY. 

No treatise on hygiene is complete without a consideration of 
the factors concerned in the protection of the animal organism 
against infection, or overcoming infection already present. Broadly 
speaking, the natural tendency of the body is to keep along the line 
of health. Any deviation from that line is promptly met by an 
effort on the part of the organism to correct its course and re-estab- 
lish a healthy equilibrium. A foreign body in the eye is instantly 
flooded with tears in order that it may be washed out. Failing in 
that, an inflammatory reaction is set up, the object being to surround 
the irritant by adhesion and thus shut it off from further irritation. 
A fractured limb is immediately placed by Mother Nature in a state 
of enforced rest, owing to the excruciating pain which the motion 
of the limb produces, and at first a temporary and then a permanent 
splint (callus) are placed around the fragments, remaining there until 
restoration of continuity. Certain poisons which are generated in 
the course of normal metabolism are neutralized and eliminated so 
as to prevent self-poisoning. A local invasion of pus-producing bac- 
teria (staphylococcus, streptococcus, etc.) is a signal for an imme- 
diate concentration of armies of leukocytes in an attempt to destroy 
the invader, and, failing in that, an effectual barrier against further 
invasion is formed through a process of inflammation which results 
in the formation of a membrane, the so-called pyogenic membrane. 
The invasion of bacteria into the general circulation, or the absorp- 



380 TEXT-BOOK OF HYGIENE. 

tion of their products (toxins), stimulates the production of sub- 
stances in the body which destroy the micro-organisms or neutralize 
their poisons. Thus, the natural forces of the body are continuously 
at work, maintaining the organism in a state of health. When these 
forces become inadequate, or are temporarily deranged, disease or a 
deviation from the normal line results. 

Immunity may be defined as a natural or acquired resistance to 
disease. Generally, the term refers to infectious diseases. Immunity 
may be racial, as the immunity of the negro to yellow fever, or indi- 
vidual; it may be active, when the result of natural infection or 
inoculation, or passive, when produced by the introduction of sub- 
stances derived from animals actively immunized, as in the case of 
antitoxin treatment. Immunity, furthermore, may express itself 
against the bacteria (antibacterial), the toxins (antitoxic), or against 
cells from an animal of a different species (cytolytic). 

In order to more fully appreciate the relation of the subject of 
immunity to hygienic problems, it may be well to consider briefly 
the two factors involved in the causation of infectious diseases. These 
are : the specific micro-organism or the exciting cause, and the resist- 
ance of the individual or the predisposing cause. The former may be 
likened to a plant-seed, the latter to the soil. Given a vigorous seed 
and a poor soil, no growth will take place. Similarly, a favorable 
soil and a poor seed will remain barren. To get the best results, both 
the seed and the soil must be in the very best condition. This is 
precisely the case in infection. A virulent micro-organism remains 
powerless in the absence of a predisposition, nor will infection occur 
in the presence of a predisposition with an avirulent micro-organism. 
As neither virulence nor resistance are constant factors, the resulting 
infection will vary in each individual case, from a mild to a fatal 
attack. The virulence of a micro-organism, under natural conditions, 
is increased by passage through the bodies of susceptible individuals, 
and decreased by passage through the bodies of relatively insusceptible 
persons. This explains the rise and fall of an epidemic. At first, 
the most susceptible individuals in a community are attacked. As 
the specific micro-organism passes through the bodies of these victims 
it gains in virulence, and the epidemic gains in fury until the most 
insusceptible individuals are reached, when the virulence of the micro- 
organism begins to decline, and the epidemic dies out. The virulence 
of bacteria may also be influenced by climatic and atmospheric con- 
ditions and by association of two or more species which either in- 
creases or decreases the virulence of the respective species. This asso- 



THEORIES OF IMMUNITY. 3gl 

ciation is known as symbiosis. On the other hand, the predisposition 
or susceptibility of the individual may be increased by bad hygienic 
surroundings, chronic poisoning, alcoholism, fatigue, and overwork 
of the nervous system, exposure to cold, improper diet, drugs, surgical 
operations, injuries, previous disease. In preventing infection, there- 
fore, we should aim at a destruction of the bacteria, or at least a 
reduction of their virulence by the use of antiseptics, etc., and at the 
same time we should enhance the resistance of the individual. In 
other words, we must render the seed inactive and the soil unfavor- 
able. 

The accepted theories of immunity are (1) MetchnikofTs theory 
of phagocytosis and (2) Ehrlich's side-chain theory. Each explains 
part of the phenomenon, and the truth probably lies between the two. 

(1) According to Metchnikoff and his followers, certain cells in 
the animal body possess, in common with ameba and other unicellular 
organisms, the property of incorporating and digesting foreign sub- 
stances. These substances are attracted by the eels by a bio-physical 
process known as chemiotaxis, which may be positive or negative, 
depending on whether the foreign body is attracted or repelled. The 
presence of the foreign body within the cell stimulates the production 
of cellular enzymes, cytases, which act as digestive ferments. The 
entire process is called phagocytosis, from the Greek <f>ayelv, to eat, 
and kvtos, cell. In the human body, two chief varieties of phago- 
cytes are present: (a) The micro phages, which are the polymorpho- 
nuclear leukocytes of the blood, and (b) the macrophages, which 
include the large mononuclear leukocytes, the fixed connective tissue 
cells, and other cells possessing phagocytic properties. The micro- 
phages exert a special digestive action on bacteria, while the macro- 
phages possess special activity toward animal cells and protozoa. 
When the digestive ferment of the microphages, the microcytase, is 
given off by the cells and is circulating in the blood, the blood-serum 
acquires bacteriolytic or cytolytic properties. 

In insusceptible or immunized animals the specific bacteria are 
attracted by the microphages and ingested and digested. However, 
before the digestion of the bacteria can take place, they must undergo 
certain alteration, and this is accomplished by a specific substance, 
also the product of the leukocytes, called fixateur, or fixative, which 
corresponds to the "immune-body" of the German schools, or the 
"opsonins" of Wright and Douglas. These opsonins are present in 
the blood of every individual to a degree proportionate to his resist- 
ance to a given infection. When infection takes place, the organism 



382 TEXT-BOOR OF HYGIENE. 

is depressed at first, and the opsonins are diminished, or what is called 
a "negative phase" takes place. As soon as the orgmism recovers 
from this primary depression, the opsonins increase, and a "positive 
phase' 5 is reached. 

Briefly stated, the process of immunity, according to Metchni- 
koff, is as follows : — 

(a) The pathogenic bacteria invade the body. 

(b) The microphages are attracted to the bacteria and the latter 
are fixed and ingested.' 

(c) The presence of the bacteria stimulates the production of 
cytase, which acts on the "sensitized" bacteria, resulting in a com- 
plete digestion of the latter or bacteriolysis. 

It will be observed that while MetclmikofFs theory explains 
immunity against the action of bacteria and toxic cells, it fails to 
explain antitoxic immunity. The latter is best elucidated by the 
theory elaborated by Ehrlich and his followers. 

2. The Lateral-chain Theory. — According to this theory, the ani- 
mal cell is made up of numerous bio-chemical atom-groups, the so- 
called biogen molecules. These groups possess specific affinities for 
similar groups in either food or other organic molecules. These 
atom-groups or side-chains in the cell are called receptors, while the 
corresponding groups in the food-molecule are called haptophores 
(from the Greek aTrretv, to touch, and <f>epav, to bring). In the process 
of nutrition, the receptors unite with the haptophores of the food- 
molecule, and thus the latter becomes an integral part of the cell. 
With food-molecules of a more complex composition, the process is 
somewhat different. Here the food-molecule cannot enter into com- 
bination with the receptor of the cell unless it is in some way modi- 
fied. This modification or elaboration of the complex food-molecule 
is accomplished by receptors possessing two different atom-groups. 
One atom-group possesses an affinity for a ferment-like substance 
present in the blood-plasma — complement — which prepares the food- 
molecule, which then combines with the other atom-group. Eecep- 
tors possessing two such atom-groups are called amboceptors. 

Extending this hypothesis to the explanation of immunity, we 
assume that a molecule of bacterial toxin behaves toward the cell very 
much like a food-molecule, with this difference: A toxin molecule 
possesses two atom-groups, a haptophorous group, which combines 
with the receptors of the cell, and a toxophorous group, which exerts a 
poisonous effect on the cell. If the amount of toxin is not sufficient 
to destroy the cell, the latter is stimulated to an over-production of 



THEORIES OF IMMUNITY. 383 

receptors, which are cast off and circulate freely in the blood. These 
free receptors anchor the toxin molecules as soon as they enter the 
circulation, and thus prevent their combining with the cells. In this 
manner antitoxic immunity is established and maintained. In the 
light of this hypothesis, antitoxin is blood-serum containing free 
receptors, and by its introduction into the system in cases of infec- 
tion (diphtheria, tetanus) we administer free receptors, which cir- 
culate in the blood and anchor the toxin molecules, which are thus 
neutralized before they can combine with the cells. The immunity 
produced by the injection of antitoxin is called passive, and is espe- 
cially characterized by its short duration, contrasting with the lasting 
immunity produced in the body of an individual who overcomes suc- 
cessfully the infection. 

In the case of the more complex bacterial bodies or toxic foreign 
cells, the amboceptors are the protective agents. Here, while one 
atom-group combines with the complement which fixes the bacteria, 
or the cells, the other destroys them. As a resuH of immunization or 
natural infection the amboceptors are produced in excess, ard the 
free amboceptors circulate in the blood, rendering it bactericidal or 
cytolytic, as the case may be. 



QUESTIONS TO CHAPTER XV. 

THE GERM THEORY OF DISEASE. 

What is meant by the germ theory of disease? When did this doctrine 
first take definite shape? When was it first clearly enunciated, and by 
whom? What basis was there then for it? What subsequent evidence soon 
developed? What was the first evidence of the parasitic nature of general 
diseases? Who discovered and who first demonstrated the true cause of 
anthrax? Who proved tuberculosis to be of microbic origin? When? What 
other diseases are now known to be caused by specific micro-organisms? 
What others are probably due to a like cause? 

What effect has the establishing of the germ theory upon preventive 
medicine? What is meant by protective inoculation? What evidence is there 
that this is possible? How do disease germs produce their characteristic 
effects upon the system? How may the inoculating material be prepared? 
How is diphtheria antitoxin prepared? How do antitoxins act? What are 
"opsonins"? What is the "opsonic index"? 

Define immunity. Name varieties of immunity. W 7 hat factors are re- 
quisite to the production of an infectious disease? How is the virulence of a 
micro-organism increased? How may the resistance of the individual be 
diminished? How may infection be prevented? Name the accepted theories 
of immunity. Describe Metchnikoff's theory. Define cytases, microphages, 
macrophages ; what are their respective functions? What are receptors? How 
is nutrition of the cell brought about? How do toxins combine with the cell? 
What is the function of amboceptors? What r6le do the receptors play in 
immunity? What is the difference in the mode of action of receptors and 
amboceptors ? 



(384) 



CHAPTER XVI. 

CONTAGION AND INFECTION. 

The adjectives "contagious" and "infectious" are used to desig- 
nate certain diseases which are propagated by immediate contact, or 
through the intervention of some other medium, from the sick to 
the healthy. The matters in which reside the morbific power are 
micro-organisms. 

The differentiation between contagion and infection is not easy. 
Many of the diseases commonly called contagious are also infectious; 
that is, they are propagated not merely by direct contact, but also 
by air, water, or food which may have become infected with the mor- 
bific agent. Syphilis, for example, may be regarded as simply a con- 
tagious disease; at the present day, at least, we cannot conceive of 
syphilis to be propagated by breathing infected air or drinking water 
contaminated with the poison of syphilis. Cholera and typhoid fever, 
on the other hand, are examples of infectious diseases, neither of 
them being directly contagious, but conveyed from sick to well through 
the medium of contaminated water, or food. Between these two stand 
small-pox and typhus fever (and perhaps the other exanthemata), 
which are not merely contagious, but infectious also. 

The contagious and infectious diseases are of particular interest 
to sanitarians, because it is believed that by judicious carrying out 
of sanitary measures they can be prevented. Hence they are some- 
times termed preventable diseases. Another peculiarity of the infec- 
tious diseases is that they usually occur in groups of cases. Thus, 
small-pox, measles, scarlet fever, typhus fever, diphtheria, and others 
of the class do not occur sporadically, as it is termed; that is to say, 
it rarely happens that only one case of small-pox is observed in a 
locality, unless active measures are at once taken to stamp it out. 
Usually a number of cases occur successively, and in most instances 
the succeeding cases can be traced ultimately to the first case. 

Contagious and infectious diseases frequently appear as epidemics. 
Authorities differ as to the proper definition of an epidemic; that is, 
given the population of a place, how many cases of an infectious or 
contagious disease are necessary before the disease can be considered 
epidemic at such place. The following formula was given by the 

25 (385) 



386 



TEXT-BOOK OF HYGIENE. 



New Orleans Medical and Surgical Association in response to the 
query : "Under what circumstances is it proper to declare such dis- 
eases (diphtheria, scarlet fever, measles, small-pox, yellow fever, etc.) 
epidemic in a place?" The answer given is that the disease should 
be declared epidemic when the number of cases should reach these 
proportions 1 : — 



For a population of 



of 100 


5 


per cent. 


500 


4 


<< tt 


2,000 to 5,000 . 


22 y 2 


" thousand. 


6,000 to 10,000 . 


16 


u <( 


" 20,000 to 50,000 . 


8 


" ten thousand 


" 50,000 to 100,000 . 


4 


« tt tt 


" 200,000 


1 


tt a tt 



A disease is said to be pandemic when it spreads rapidly over a 
great extent of country, and endemic when it is constantly present in 
a place. Diseases which may be prevalent in certain localities, i.e., 
endemic, not infrequently spread over larger areas of country — over- 
flow their borders, as it were — and become epidemic or pandemic. 
Thus cholera, which is endemic in certain districts of India, fre- 
quently spreads over adjacent territorj T , and at times the epidemic 
wave, as it has been called, rolls over nearly the whole world. Plague, 
malarial and yellow fevers make similar epidemic excursions into 
other countries, or sections of country, at a distance from the places 
where they are endemic. 

Contagious and infectious diseases possess another peculiarity in 
that a certain time is required after the introduction of the poison 
into the system before the disease manifests itself by its typical symp- 
toms. This is called the "stage of incubation," and varies for dif- 
ferent diseases. The following table shows the stage of incubation of 
a number of such diseases: — 

Table LVI. 

Incubation of Infectious Diseases. 

Measles 

Small-pox 

Mumps 

Diphtheria 

Scarlet fever 

Whooping-cough 

Typhoid fever 

Typhus fever 1 to 2 

Chicken-pox 4 

Erysipelas 4 



10 


days 


12 


" 


18 


tt. 


3 


" 


3 


<( 


14 


it 


14 


tt 



1 Public Health, vol. vi, p. 416, 417. 



THE CARRIERS OF INFECTION. 387 

The period during which the infectiveness of the patient lasts 
also varies. In some cases it probably depends upon the measures 
taken to prevent the spread of the disease, e.g., disinfection of the 
patient and his surroundings. 

The London Clinical Society has made public a report by one of 
its committees, which has for several years carefully studied the ques- 
tions of incubation and the duration of infection. The conclusions 
reached do not differ essentially from those in the above table, but 
as they are given somewhat more in detail they are here appended : — 

Diphtheria, two to seven days; oftenest two. 

Typhoid fever, eight to fourteen days; sometimes twenty-three. 

Influenza, one to four days; oftenest three to four. 

Measles, seven to eighteen days; oftenest fourteen. 

Mumps, two to three weeks; oftenest three weeks. 

Eubeola, two to three weeks. 

Scarlet fever, one to seven days; oftenest two to four. 

Small-pox, nine to fifteen days; oftenest twelve. 

Further investigations were made with regard to the time and 
duration of the infective period. 

Diphtheria was found to be infective during the period of incu- 
bation, attack, and convalescence. 

Mumps and rubeola are also infective for three or four days 
before the onset of the parotiditis and appearance of the rash. 

The contagiousness of measles speedily disappears, and does not 
continue in disinfected persons for over three weeks. 

Typhoid fever is infectious from the time of onset until two 
weeks after the fever has gone and convalescence set in. 

As is well known, the contagiousness of scarlet fever varies 
greatly, but is generally continued a very long time — certainly until 
desquamation ceases, and sometimes as long as eight weeks. 

THE CARRIERS OF INFECTION. 

The germs of infectious or contagious diseases may be conveyed 
either by inanimate objects which come in contact with the original 
source of the disease or by living animals. Of the former, air, food, 
water, and clothing, the latter included under the general term 
"fomites," have already been discussed. The transmission of disease 
by animals, especially by insects, is a subject which has assumed con- 
siderable importance of late. Leaving aside the strictly animal dis- 
eases which are communicable to man, as anthrax, glanders, hydro- 
phobia, actinomycosis, etc., we will consider only the instances in 



388 TEXT-BOOK OF HYGIENE. 

which the animal acts as a passive agent, or an intermediary host. 
Thus, oysters from sewage-polluted beds have been responsible for 
epidemics of typhoid fever. The bacillus coli has been found in the 
bodies of such oysters, while Chantemesse and others have demon- 
strated the possibility of oysters carrying the typhoid bacillus. Certain 
snails appear to be intermediate hosts for worms parasitic to man. The 
most important disease-carriers, however, are the insects. These may 
either convey the germs mechanically, or inoculate them by stinging or 
biting, or act as intermediate hosts. Thus, flies may carry on their 
legs or within their bodies the germs of cholera, typhoid fever, tuber- 
culosis, and other infectious diseases, and deposit them on the food 
or drink which is subsequently consumed by man. There is abundant 
evidence to prove that in many instances epidemics of typhoid fever 
have been caused through the agency of the domestic fly. During 
the Spanish-American War several camps were visited by epidemics 
of typhoid fever, and in every instance flies were demonstrated as 
the carriers of the infection. Fleas, bed-bugs, spiders, and lice 
may and often do transmit disease by biting the individual and 
inoculating the wound with the bacteria which are present on the 
proboscis. In the case of mosquitoes, there are "certain species 
which act as the intermediary host and are essential factors in 
the propagation of disease. Thus, the plasmodium malaria?, a pro- 
tozoon which is the specific cause of that disease, undergoes two 
cycles of development: an asexual cycle in the human body, and a 
sexual cycle in the body of the mosquito of the genus anopheles. 
When the mosquito draws the blood from a person suffering from 
malaria, the flagellate forms of the parasite (microgametocytes) are 
developed in its stomach. The flagella {micro gametes, or male ele- 
ments) are discharged, move towards other non-flagellated forms of 
the parasite (macrogametes, or female elements) and fertilize them. 
The fertilized parasites then invade the intestinal wall and form a 
cystic structure (oocysts), containing numerous minute rods or sporo- 
zooits which have resulted from the segmentation of the parasite. 
The oocysts eventually rupture and the sporozooits find their way 
into the veneno-salivary glands of the mosquito, to be introduced into 
the next person who is so unfortunate as to receive the sting of the 
infected mosquito. Once in the circulation of man, the parasites in- 
vade the red blood-cells and there undergo multiplication by segmen- 
tation. 

Recently it has been demonstrated that yellow fever is transmitted 
by another species of mosquito, stegomyia fasciata, probably in a simi- 



THE CARRIERS OF INFECTION. 389 

lar manner; while Manson has shown that the mosquito (culex) 
acts as the intermediary host of the parasite of elephantiasis (filaria 
sanguinis hominis). 

Of the higher animals, rats have been shown to be the carriers of 
bubonic plague, a disease to which they are subject. 

The prophylaxis of diseases transmitted by insects and the higher 
animals is to be accomplished by cleanliness, destruction of the pests 
whenever possible, and avoidance of contact with animals harboring 
the germs of disease. 



QUESTIONS TO CHAPTER XVI. 

CONTAGION AND INFECTION. 

What is the difference between a contagious and an infectious disease? 
Give examples of each. What diseases do not belong to either of these classes? 
What other names might be gwen to contagious and infectious diseases? How 
do they usually occur? What are their exciting causes? How may they be 
prevented ? 

What is an epidemic? When may a disease be declared epidemic in a 
city of 10,000 persons? When is a disease pandemic? Wlien endemic? May 
an endemic disease become epidemic or pandemic? 

What other peculiarities do contagious and infectious diseases possess? 
What diseases have the longest period of incubation ? What ones the shortest ? 
How does the period of incubation support the germ theory? What other 
definite period has each of these diseases? What is the usual duration of a 
case of typhoid fever? Of scarlet fever? Of measles? Does this support the 
germ theory? How long does a typhoid patient remain infective? How long 
a diphtheria patient? A scarlet-fever patient? (See chapters on School Hy- 
giene and Quarantine.) Upon what does the danger and period of infective- 
ness depend? Are these diseases all likely to confer immunity against future 
attacks? Which are most likely to do this? What role do animals play in 
the transmission of disease? Name insects which act as intermediate hosts 
in the transmission of malaria. Of yellow fever. Describe the mode of 
transmission of malaria by the mosquito. 



(390) 



CHAPTER XVII. 

HISTORY OF EPIDEMIC DISEASES. 

An important part of the knowledge of the sanitarian is that 
which relates to the history of the great epidemic diseases which have 
at various periods devastated large areas of the inhabited world. In 
this chapter the history of these diseases will be briefly traced. Al- 
though some of these diseases have nearly or quite ceased, a knowledge 
of their habits and of the causes that finally led to their extinction 
is of great value, for the reason that the principles and measures of 
prevention which were effective in times past are the same which 
must apply at present and in the future. Hence, time spent' in look- 
ing back over the fields traversed and noting victories won will not be 
wasted. 

The epidemic diseases which will here claim attention are the 
Oriental plague, the sweating sickness, small-pox, Asiatic cholera; 
typhus, typhoid, scarlet, relapsing, and yellow fevers; diphtheria, 
dengue, epidemic influenza, and syphilis. In addition, some informa- 
tion will be given on certain of the diseases of animals transmissible 
to man. Among these are sheep-pock, actinomycosis, bovine tuber- 
culosis (perlsucht), rabies, anthrax (milzbrand), and glanders. 

THE ORIENTAL PLAQUE. 

The Oriental plague, bubonic plague, the black death, or simply 
the "plague," or great pestilence, overtopping in its fatality all other 
pestilences, is mentioned by a number of the Greek and Latin medical 
authors. The first account which clearly refers only to this disease 
is given by Procopius. According to this and other contemporary 
authors, the disease began to spread in the year 542 from Lower 
Egypt, passing in one direction along the coast of Northern Africa, 
and in the other invading Europe by way of Syria and Palestine. In 
the course of the succeeding years this pandemic reached "the limits 
of the inhabited earth," in the language of the writers of the day. 
The disease prevailed about half a century, and produced the greatest 
devastation wherever it appeared. "Cities were devastated, the country 
converted into a desert, and the wild beasts found an asylum in the 
abandoned haunts of man." 1 



1 Warnef ried, quoted by Hirsch, Hist-Geographische Pathologie, I, p. 350. 

(391) 



392 TEXT-BOOK OF HYGIENE. 

The plague is an acute infectious disease caused by a bacillus 
(bacillus pestis) and characterized by an affection of the lymphatic 
system, i.e., inflammation and swelling of the external and internal 
lymphatic glands. Accessory symptoms are petechial spots upon the 
skin, and hemorrhages from various organs, as the stomach, nose, 
kidneys, rectum, and uterus. Those attacked suffer in varied degrees 
of intensity. In some, a fulminant form occurs which carries off the 
patient within three days ; there is another class of cases in which 
buboes develop, with accompanying fever and hemorrhages; and 
finalty, a light form, rarely fatal, in which only the local symptoms 
are manifested. In the great pandemic plague of the fourteenth cen- 
tury cough and bloody expectorations were very frequent. In the 
later epidemics hemorrhage from the lungs has been rarely noticed 
as a symptom. 

About the middle of the fourteenth century the bubonic plague 
made a second incursion into Europe from its home in the East. A 
most graphic description of its ravages is given by Boccaccio in the 
"Decameron." This author states that in 1359, between March and 
July following, according to authentic reckonings, upward of 100,000 
souls perished in the city (Florence) ; whereas, before that calamity 
it was not supposed to contain so many inhabitants." 

This terrible epidemic was forcibly characterized by its com- 
mon name, "the black death." Hecker estimates that during its con- 
tinuance, from 1347 to 1351, 25,000,000 — one-fourth of the probable 
total population of Europe — died. In various cities the mortality was 
—in London, 100,000; in Paris, 50,000; in Venice, 100,000; in 
Avignon, 60,000; in Marseilles, 16,000, in one month. It was said 
that in all England scarcely a tenth part of the population escaped 
death from the disease. 

The moral effects of this great pandemic of the plague were 
hardly less deplorable than the physical. Eeligious fanaticism held 
full sway throughout Europe, finding its vent in all manner of ex- 
cesses. The so-called Brotherhood of the Cross, otherwise known as 
the Order of Flagellants, which had arisen in the thirteenth century, 
but had been suppressed by the ecclesiastical authorities, was revived 
during the black pestilence, and large numbers of these religious 
enthusiasts roamed through the various countries on their great pil- 
grimages. Their power increased to such a degree that Church and 
State were forced to combine for their suppression. One consequence 
of this fanatical frenzy was the persecution of the Jews. These were 
accused of being the cause of every evil that befell mankind, and 
many were put to death, 



THE ORIENTAL PLAGUE. 393 

In the fifteenth and sixteenth centuries the plague was generally 
diffused throughout Europe, and in the second third of the seventeenth 
century its final incursion into the Occident took place. The great 
epidemic in London, so graphically described by Defoe, 2 occurred in 
1665. In the early part of the eighteenth century (1720) the plague 
visited Marseilles and Toulon ; from 1769 to 1772 it was epidemic in 
Moldavia, Wallachia, Poland, and Southern Eussia; near the close 
of the eighteenth and in the beginning of the nineteenth century, 
in Trans}dvania, Wallachia, Southern Eussia, and Greece. In 1878 
and 1879, and in 1885, the plague threatened a new irruption into 
European territory, being epidemic in the district of Astrachan, on the 
Caspian Sea. In 1894 it was reported epidemic in certain parts of 
China. 

Although the bubonic plague has never been observed in America 
in epidemic form, and has spared Enrope almost entirely during the 
present century, it still persists in certain countries of Asia and 
Africa, especially in Arabia, Mesopotamia, Persia, and the coast of 
Tripoli. A number of cases of plague occurred a few years ago in 
San Francisco, in the Chinese quarters. 

The older authors ascribed the origin of the plague to various real 
or supposed conditions. Comets, conjunctions of the planets, "God's 
just punishment for our sins/' and similar causes were advanced 
to account for the outbreaks. Most of the writers of the post-medieval 
and modern epochs ascribed the disease to meteorological conditions. 
Observing the fact that the plague never advanced into the torrid 
zone, and that an epidemic generally ended with the advent of hot 
weather, a high temperature was believed to be incompatible with the 
existence of an epidemic, and a cold or temperate climate was con- 
sidered necessary to an outbreak of the disease. The exceptions to 
the rule are so numerous, however, that the theory of the climatic 
or meteorological origin of the plague failed of support. The theory 
which ascribed the origin of the epidemics to the influence of cer- 
tain hot and dry winds or a high humidity is also insufficient. Cer- 
tain geological formations have been supposed to furnish favorable 
conditions for the development of the disease. Facts show, however, 
that the disease has prevailed epidemically and endemically in vari- 
ous parts of the earth, and of the most diverse geological character. 
A certain elevation above sea-level has been held to confer immunity, 
but recent observations in India show that this belief is unfounded. 



.Journal of the Plague in London. 



394 TEXT-BOOK OF HYGIENE. 

even places at an elevation of 10,000 feet above sea-level giving no 
security against attack. 

There is, however, one point upon which nearly all writers who 
mention the fact at all agree. That is that bad hygienic conditions 
are always present where plague prevails. Nearly all observers who 
have left their impressions on record mention the accumulation of 
filth in the houses and streets, deficient removal of excrementitious 
and other sewage matters, crowding and imperfect ventilation of 
dwellings as causes favoring the development and spread of the pes- 
tilence. All point out the necessity of the removal of these evils as 
the most important prophylactic measure to be adopted, and all of 
them call attention to the fact that those classes of the population 
most exposed to these unfavorable influences suffer most from the 
violence of the epidemic. 

The later reports of the epidemics in Persia, India, Mesopotamia, 
and Eussia agree in asserting that nothing seems to have promoted 
the epidemic and endemic prevalence of the plague so much as the 
material wretchedness of the inhabitants of those countries. In a 
collection of papers on the plague, printed by a British Parliamentary 
Commission in 1879, occur these statements: "The filth is every- 
where," says Mr. Eennie, one of the reporters — "in their villages, their 
houses, and their persons. Their dwellings are generally low and ill- 
ventilated, except through their bad construction; and the advan- 
tage of the natives in other parts of India, of living in the open air, 
is lost to the villagers of Ghurwal, from the necessity of their crowd- 
ing together for mutual warmth and shelter against the inclemency 
of the weather/' Dr. Dickson, reporting on the plague in Irak Arabi, 
in 1876, says: "The most palpable and evident of all the causes 
which predispose an individual to an attack of plague during an 
epidemic outbreak is poverty. No other malady shows the influence 
of this factor in so striking a degree; so much so, indeed, that Dr. 
Cabiadis styles the plague misericB morbis. In his experience (1876- 
77, in Bagdad) he found that the poor were seldom spared, the 
wealthy hardly ever attacked." 3 

The manner of the transmission of the plague has now been dis- 
covered to be by infected rats and fleas. Hence, it may be termed an 
infectious disease, although it is not improbable that it may be com- 
municated by direct contact both of persons and of fomites. 

These considerations indicate the measures of prevention to be 



8 Hirsch, op. cit., p. 370. 



THE SWEATING SICKNESS. 395 

adopted. They consist of a rigid quarantine of persons and fomites, 
prompt and complete isolation of infected individuals and localities, 
and destruction (by fire) or thorough disinfection by steam or sul- 
phurous-acid gas of all materials capable of conveying the virus of 
the disease, and especially the destruction of rats. 

THE SWEATING SICKNESS. 

This name concisely characterizes an epidemic disease which 
for the first time appeared in the city of London and other parts of 
England in the autumn of 1485. According to Lord Bacon, 4 the 
disease began about the 21st of September and lasted until near the 
end of October. It broke out a second time in the summer of 1507; 
a third time in July, 1518, spreading in the course of six months 
throughout England. In May, 1529, the disease made its appearance 
again in the latter country, spreading thence over a great part of 
the continent of Europe. Another very malignant epidemic broke 
out in the spring of 1541, lasting through the summer, and limited 
in its ravages to England. 

With this outbreak, in 1551, this disease disappeared entirely in 
England, and has not re-appeared there up to the present day. In the 
beginning of the eighteenth century, however, a disease very similar in 
its symptoms and course broke out in Picardy and other districts of 
Northern France, being confined for a number of years to this sec- 
tion of the country. Toward the end of the century it spread to the 
south of France, and since that time has appeared epidemically at 
intervals, 195 distinct outbreaks having been observed in the course 
of 168 years, from 1718 to 1887. The disease has frequently appeared 
in Italy since 1755, and in various parts of Germany since 1801. In 
Belgium it has been observed at a few places within the present 
century. 

The disease appeared suddenly, often at night-time. The patient 
was attacked with palpitation of the heart, dyspnea, great anxiety and 
oppression, and profuse perspiration. A miliary eruption often ap- 
peared on the skin. In favorable cases these symptoms diminished 
in the course of one or two days, the urinary secretion, which had 
been suppressed, was restored, and the perspiration became gradually 
less free. Eecovery ensued in from one to two weeks. In grave cases 
there were, in the beginning of the attack, violent headache, delirium, 



History of Henry VII. 



396 TEXT-BOOK OF HYG1EXE. 

convulsions, followed by a comatose condition, from which the patients 
rarely recovered. 

This disease is undoubtedly of an infectious nature, as proved by 
its rapid spread and limitation to certain localities. It appears most 
frequently in the spring and summer, and is nearly always observed in 
marshy or clamp localities. Its spread is favored by a high tempera- 
ture and humidity. There is no apparent connection between the 
outbreaks of the sweating sickness and overcrowding or other unsani- 
tary conditions; in fact, it is stated by numerous observers, both old 
and recent, that children, the aged, and generally the poorer classes 
were remarkably exempt from the disease. The recent epidemic in 
France, in 1887, was investigated by Dr. Brouardel, Chantemesse, 
and. other epidemiologists, but no trustworthy conclusions as to the 
nature of the disease have yet been reached. 

Since the first appearance of Asiatic cholera in France, in 1832, 
an apparently intimate connection has been observed between the oc- 
currences of that disease and outbreaks of sweating sickness. A 
disease strongly resembling the sweating sickness has also been ob- 
served in India in districts contiguous to places where cholera was 
at the time epidemic. 5 

SMALL=POX. 

The earliest details concerning small-pox are derived from cer- 
tain Chinese records, according to which it appears that this disease 
was known in China upward of 2000 years ago. It was also known at 
a very early period in India. It is believed to have been introduced 
into Europe in the second century by a Eoman army returning from 
Asia. It is believed that the Emperor Aurelius died of small-pox, 
which prevailed in his army at the time of his death. 

The first distinct references to small-pox in medical literature 
occur in the writings of Galen, in the second century. Ehazes, in the 
ninth century, wrote upon the disease, describing it very accurately. 

The almost universal susceptibility to small-pox caused wide- 
spread devastation wherever it appeared previous to the introduction 
of vaccination. The statement is made that in England, in the last 
century, about one person in every three was badly pock-marked. The 
mortality from the disease was exceedingly great, being, in the latter 
half of the eighteenth century, about 3000 per million of inhabitants 
annually. 



5 Murray, Madras Quart. Med. Journ., 1840-41. Quoted in Hirsch, loc. 
cit., p. 83. 



SMALL-POX. 397 

In India the mortality from small-pox has been exceedingly great 
within the last twenty years. From 1866 to 1869, 140,000 persons 
died in the Presidencies of Bombay and Calcutta, having a population 
of about 40,000,000. Several years later, from 1873 to 1876, 700,000 
died from this disease. 

China, Japan, Cochin China, the islands of the China Sea, and 
Corea are frequently ravaged by small-pox. In the latter country 
nearly all the inhabitants are said to bear evidence of an attack of 
the disease. 

The Samoyedes, Ostiaks, and other natives of Eastern Siberia 
have frequently suffered from devastating epidemics. In Kamtchatka 
the disease was introduced in 1767 and produced frightful ravages. 
Many villages were completely depopulated. 

In Mexico small-pox was introduced by the Spaniards in 1520. 
In a short time it carried off over 3,500,000 of the natives. In the 
Marquesas Islands one-fourth of the inhabitants have fallen victims 
to the disease since 1863. 

It was first introduced into the Sandwich Islands in 1853, and 
carried off 8 per cent, of the natives. 

Australia, Tasmania, New Zealand, and the Fejee Archipelago 
remain exempt to the present day from small-pox. It has several 
times been carried to Australia by vessels, but has always been 
promptly checked by the vigilance of the authorities. 

On the Western Hemisphere small-pox was unknown before the 
arrival of the European conquerors. It has been spread by the whites 
or imported African slaves to nearly all the Indian tribes of both 
continents. When it attacks large communities unprotected by pre- 
vious outbreaks of the disease, or by inoculation or vaccination, its 
ravages are frightful. The mortality of unmodified small-pox is 
usually between 30 and 40 per cent. 

Small-pox is a highly contagious and infectious disease. It is 
produced by actual contact, by inoculation, and by inhaling an at- 
mosphere charged with the poison. In order to cause an outbreak 
two factors are necessary: first, a number of individuals susceptible 
to the disease, and, second, the introduction into the body in some 
manner, of the virus upon which it depends. 

Small-pox is spread from (1) persons sick with the disease; (2) 
others, not themselves sick or susceptible, but coming in contact with 
the poison; (3) fomites (cotton, wool, etc.), and (4) the bodies of 
persons dead with small-pox. It is also probable that the air in the 



398 TEXT-BOOK OF HYGIENE. 

immediate vicinity of a person sick with small-pox becomes charged 
with the poison and able to convey the disease. It is at present impos- 
sible to fix the distance to which this infectiousness of the air ex- 
tends, but it does not ordinarily reach beyond the room in which the 
patient is confined. 

It is a fact of common observation that the darker races are 
more commonly attacked, and the disease is likewise more fatal 
among them. The mortality among negroes is much larger than 
among other races. 

It is a current belief that small-pox is only contagious after the 
development of the pustules. This is a serious error. It is probably 
contagious in all stages of the disease; certainly as early as the first 
appearance of the eruption, and probably even in the stage of prelim- 
inary fever. 

One attack of small-pox usually confers immunity from the dis- 
ease for life. This rule has its exceptions, however, which, if not 
numerous, are yet not infrequent. The author has seen a case in 
which the patient suffered from a third attack of the disease. 

The popular belief, that persons suffering from any acute or 
chronic disease are less liable to be attacked by small-pox than those 
at the time in good health, is erroneous. On the contrary, the subjects 
of chronic disease, such as consumption or dyspepsia, are much more 
liable to succumb to an attack of small-pox than persons previously in 
good health. 

It is true, however, that individuals suffering from some other 
acute infectious disease, like scarlet fever, measles, typhoid fever, 
etc., are generally, though not absolutely, exempt from an attack of 
small-pox during the time they are sick with such disease. But if 
they are exposed, after recovery, to the small-pox infection, their 
liability to an attack is as great as in those who have not passed 
through a similar disease. A number of cases have been reported by 
Curschmann, 6 in which infection by small-pox took place on the day 
in which convalescence from typhoid fever was established. 

The author has reported a case 7 in which the patient passed 
through an attack of erysipelas during the incubative stage of small- 
pox. From all the evidence attainable, the incubative stage was not 
prolonged by the intercurrent erysipelas. 

Epidemics of small-pox usually begin in the autumn or winter, 
and lessen in violence as warmer weather approaches. The spread 



e Ziemssen's Cyclopaedia, vol. ii. 
7 Medical News, July 7, 1883. 



SMALL-POX. 399 

of the disease is slow at first, increasing in rapidity as the foci of 
infection multiply. 

When the poison is imported into a community late in the spring 
or during the summer, the increase in the number of cases is ex- 
ceedingly gradual until colder weather sets in. If it is introduced dur- 
ing the winter, the disease spreads much more rapidly, but decreases, 
and sometimes almost disappears, during the summer. On the return 
of cold weather, however, the epidemic starts out with a new lease 
of activity and presents great difficulties to its restriction. 

A number of observers, among whom are Coze and Feltz, Lugen- 
biihl, Weigert, Strauss, Garre, and Wolff, claim to have discovered 
specific organisms in the contents of variolous pustules, in the blood 
of patients with the disease, and in vaccine lymph. Expert bacterio- 
logists are, however, not willing to accept the evidence hitherto fur- 
nished as conclusive. 

Inoculation. — The prevention or restriction of such a universal 
and fatal pestilence as small-pox is a matter of the deepest impor- 
tance. The first attempt to limit its fatality dates from the end of 
the seventeenth century. It became generally known in Europe, 
about the year 1700, that the intentional inoculation of variolous 
matter into healthy individuals induced an attack of the disease, which 
generally ran through its various stages with less virulence than when 
the disease was contracted in the usual manner. In 1716 and 1717 two 
papers were published in the "Transactions of the Eoyal Society of 
England" giving an account of the process of inoculation. The at- 
tention of the public was especially directed to the matter, however, 
by the famous letter of Lady Mary Wortley Montagu, dated April 
1, 1717. This letter is as follows 8 : "Apropos of distempers, I am 
going to tell you a thing that will make you wish yourself here. The 
small-pox, so fatal and so general amongst us, is here entirely harm- 
less by the invention of ingrafting, which is the term they give it. 
There is a set of old women who make it their business to perform 
the operation every autumn, in the month of September, when the 
great heat is abated. People send to one another to know if any of 
their family has a mind to have the small-pox ; they make parties for 
this purpose, and when they are met— commonly fifteen or sixteen 
together — the old woman comes with a nut-shell full of the matter of 
the best sort of small-pox, and asks what veins you please to have 
opened. She immediately rips open that you offer to her with a large 
needle — which gives you no more pain than a common scratch — and 

•The letter is addressed to Mrs. S. C. (Sarah Chiswell). 



400 TEXT-BOOK OF HYGIENE. 

puts into the vein as much matter as can lie upon the head of her 
needle, and after that binds up the little wound with a hollow bit 
of shell; and in this manner opens four or five veins. The Grecians 
have commonly the superstition of opening one in the middle of the 
forehead, one in each arm, and one on the breast, to make the sign 
of the cross; but this has a very ill effect, all these wounds leaving 
little scars, and is not done by those that are not superstitious, who 
choose to have them in the leg or that part of the arm that is con- 
cealed. The children or young patients play together all the rest of 
the day, and are in perfect health until the eighth. Then the fever 
begins to seize them, and they keep their beds two days, very seldom 
three. They have rarely above twenty or thirty in their faces, which 
never mark; and in eight days' time they are as well as before their 
illness. Where they are wounded there remain running sores during 
the distemper, which I don't doubt is a great relief to it. Every year 
thousands undergo this operation; and the French ambassador says 
pleasantly: 'They take the small-pox here by way of diversion, as 
they take the waters in other countries/ There is no example of any 
one that has died in it, and you may believe that I am well satisfied 
of the safety of the experiment, since I intend to try it on my dear 
little son. 

"I am patriot enough to take pains to bring this useful invention 
into fashion in England ; and I should not fail to write to some of our 
doctors very particularly about it, if I knew any of them that I 
thought had virtue enough to destroy such a considerable branch of 
their revenue for the good of mankind. But that distemper is too 
beneficial to them not to expose to all their resentment the hardy 
wight that should undertake to put an end to it. Perhaps, if I re- 
turn, I may, however, have courage to war with them." 

Soon after the date of this letter the writer's son was inoculated 
in Turkey, and four years later her daughter also, being the first sub- 
ject inoculated in England. The practice soon became popular, but 
several fatal cases among prominent families brought it into disrepute, 
and for about twenty years very few inoculations were made in Eng- 
land. It was revived about the middle of the century by the founding 
of a small-pox and inoculation hospital in London. This continued 
in operation until 1822. The records of this institution showed that 
only three in a thousand died of the disease thus communicated. The 
practice has now fallen into desuetude, being superseded by vaccina- 
tion and prohibited by law in England. 

Inoculation was introduced into this country in 1721 by Dr. Zab- 



SMALL-POX. 401 

diel Boylston, of Boston, who had his attention directed to the prac- 
tice by Cotton Mather, the eminent divine. 9 During 1721 and 1722, 
286 persons were inoculated by Boylston and others in Massachu- 
setts, and 6 died. These fatal results rendered the practice unpopular, 
and at one time the inoculation hospital in Boston was closed by 
order of the Legislature. Toward the end of the century an inoculat- 
ing hospital was again opened in that city. 

Early in the eighteenth century inoculation was extensively 
practiced by Dr. Adam Thomson, of Maryland, who was instrumental 
in spreading a knowledge of the practice throughout the Middle 
States. 10 

In China and India, and perhaps other eastern countries, inocu- 
lation was practiced at a very early period. 

The inoculation of variolous matter, although it mitigated to 
a very great degree the attack of small-pox following, had one very 
serious objection, aside from the small death-rate which was a direct 
consequence of it. This was the fact that inoculation always pro- 
duced small-pox, and thus assisted in propagating the disease; for. 
however mild the induced disease might be, the inoculated individual 
was liable to communicate small-pox to others in the most virulent 
form. Hence, nothing short of universal inoculation, which was mani- 
festly impracticable, would succeed in reducing the danger from the 
disease. 

Vaccination. — It had been noticed at various times that a pus- 
tular disease which sometimes appears on the udders of cows, called 
cow-pox, had not infrequently been transmitted to the hands of the 
dairy-maids and others having much to do with cows. In the course 
of time it was also noticed that persons who had been thus attacked 
never suffered from small-pox. This protective power of cow-pox was 
known as early as 1713, and in 1774 Benjamin Jesty, a Gloucestershire 
farmer, performed vaccination for the first time on record, inoculating 
his wife and two sons with cow-pox matter as a protection against 
small-pox. 

It is said that when it became known that Jesty had vaccinated 
his wife and sons, "his friends and neighbors, who had hitherto looked 
upon him with respect, on account of his superior intelligence and 
honorable character, began to regard him as an inhuman brute, who 

9 Dr. John R. Quinan (Md. Med. Journ., June 23 and 30, 1883) believes 
the claim of Dr. Boylston to be the first American inoculator open to ques- 
tion. The evidence presented is, however, insufficient to discredit the claim 
of the Boston physician. 

10 See Quinan, loc. cit., p. 114. 



402 TEXT-BOOK OF HYGIENE. 

could dare to practice experiments upon his family, the sequel of 
which would be, as they thought, their metamorphosis into horned 
beasts. Consequently the worthy farmer was hooted at, reviled, and 
pelted whenever he attended the markets in his neighborhood/' 11 

In 1791 a school teacher in Holstein also inoculated three boys 
with the matter of cow-pox, but nothing is known of the subsequent 
history of these cases. 

Although the above facts are clearly established, it is to Edward 
Jenner, a modest country doctor of Berkeley, in the county of Glou- 
cester, England, that the merit of demonstrating the protective power 
of cow-pox against small-pox, and of diffusing a knowledge of this 
fact, is due. Jenner had his attention directed to the asserted pro- 
tection conferred by cow-pox during the period of his apprentice- 
ship. After a residence in London as a pupil of John Hunter, he 
returned to the country to practice his profession. About the year 
1776 he began studying the question, and gathering evidence of the 
protection afforded against small-pox by the accidental inoculation of 
cow-pox virus. For twenty years he studied the subject, patiently 
awaiting an opportunity to put his belief to the test of experiment. 
On the 14th of May, 1796, he made his first vaccination on a boy 
named James Phipps. Six weeks later he inoculated this boy with 
variolous matter, but without success, no small-pox resulting. Two 
years later he published his pamphlet, entitled "An Inquiry into the 
Causes and Effects of the Variola Vaccinae," etc., in which he detailed 
his observations and experiments. This publication produced a great 
sensation in the medical world, and, although much opposition was 
at first manifested towards his views, he soon gained many adherents. 

Vaccination, as the operation for the inoculation of cow-pox virus 
is termed, was rapidly introduced into all civilized countries, and soon 
demonstrated its good effects by greatly restricting the prevalence of 
small-pox. It is generally believed that the first one to practice vac- 
cination in this country was Dr. Benjamin Waterhouse, of Boston, 
in the summer of 1800 ; but Dr. John E. Quinan has recently shown 12 
that vaccination was introduced into Maryland, by Dr. John Craw- 
ford and Dr. James Smith, at least as early as the date generally as- 
signed for its introduction into Massachusetts. 

It was believed by Dr. Jenner, and afterward conclusively shown 
by a number of distinguished experimenters, that vaccinia, as the dis- 
ease produced by cow-pox inoculation was called, was merely a modi- 

11 London Lancet, September 13, 1862. 

12 Quinan, loc. tit., pp. 118, 131. 



SMALL-POX. 403 

fication of small-pox as it existed in the cow. Small-pox virus, when 
inoculated upon the cow, produced cow-pox; but the latter, re-inocu- 
lated upon man, produced cow-pox (vaccinia), and not small-pox. 
These experiments, however, have not been successful in all instances, 
and the identity of the two diseases, while generally recognized, is 
not absolutely established. Sheep-pock and horse-pock, or "grease/' 
are probably merely modifications of the disease produced by inocu- 
lating small-pox into those animals. 

When cow-pox virus is successfully inoculated into the human 
system — that is, when a person is successfully vaccinated — the fol- 
lowing local and general symptoms are observed: — 

In the case of a primary vaccination, i.e., where the individual 
has not been previously vaccinated or attacked by small-pox, the point 
where the vaccination is made shows no particular change for the 
first two days. If the vaccination is successful, a small, reddish pap- 
ule appears by the third day, which, by the fifth or sixth day, has be- 
come a distinct vesicle of a bluish-white color, with a raised edge and 
a peculiar, central, cup-like depression called the umbilication. By 
the eighth day this vesicle has become plump, round, and pearl-col- 
ored, the central umbilication being still more marked. At this time 
a red, inflamed circle, called the areola, appears, surrounding the 
vesicle and extending usually in a radius of from one-half to two 
inches when fully developed. This inflammatory ring is pretty firm, 
and there is more or less general fever and often enlargement and 
tenderness of the axiliary glands. After the tenth day the areola 
begins to fade, and the contents of the vesicle dry into a hard, brown- 
ish crust or scab, which falls off between the twentieth and twenty- 
fourth days, leaving a punctated scar, which gradually becomes white. 

When the vaccinia has passed through all of these stages, espe- 
cially if the vesicle filled with pearly lymph, and the areola have been 
well developed, the vaccination may be considered a success, and the 
individual protected against small-pox for a number of years, if not 
for life. Eecently the doctrine has been strongly advocated that vac- 
cination is not absolutely protective until a subsequent inoculation 
of vaccine fails to "take." According to this view, vaccination should 
be repeated until it fails any longer to exhibit any local reaction. 
When this has been attained the individual may be considered abso- 
lutely protected for life. Theoretically, this view has much in its 
favor, but there is, as yet, not sufficient evidence to establish it as a 
law. 

It may be stated as an established fact that vaccination, although 



404 TEXT-BOOK OF HYGIENE. 

carefully performed and successful, does not confer absolute immu- 
nity from small-pox for life. The protective power seems to wear 
out after a time and the individual then again becomes susceptible 
to small-pox. An attack of small-pox in a vaccinated individual is, 
however, nearly always much milder than where there had been 
no vaccination. There is no fact in the entire range of medicine bet- 
ter established than this: that small-pox in vaccinated persons is a 
much less dangerous disease than typhoid fever, while in unvaccinated 
cases the mortality ranges from 30 to 40 per cent. An approximate 
guide to the beneficent influence of vaccination upon the mortality 
from small-pox is furnished by a table in Seaton' s report on vaccina- 
tion. Before the introduction of vaccination the mortality from 
small-pox per million of inhabitants of England, was nearly 3000 per 
year. After the introduction of vaccination the mortality was re- 
duced to 310 per million per year. 

The most remarkable and convincing statistical evidence on the 
question is given by Drs. Seaton and Buchanan, of England. Dur- 
ing the small-pox epidemic in London, in 1863, they examined over 
50,000 school-children, and found among every thousand without evi- 
dence of vaccination 360 with scars of small-pox, while of every 
thousand presenting some evidence of vaccination only 1.78 had any 
such traces of small-pox to exhibit. 13 The reliability of general mor- 
tality statistics may be called in question — in some cases, with justice ; 
but the significance of these figures cannot be evaded. 

The upper and outer surface of the arm is usually chosen as the 
point where the virus is inserted, although any part of the body which 
can be protected against friction, or other mechanical irritation, may 
be selected. The method varies slightly in the hands of different 
vaccinators. The two methods most frequently in use are scarifica- 
tion and erasion. The former method has the indorsement of Mr. 
Seaton, the high English authority. The method of erasion — scrap- 
ing off the epidermis until the papillary layer of the skin is laid 
bare — is now most frequently used in this country. The best instru- 
ment to use is a clean thumb-lancet; in default of this, an ordinary 
sewing-needle answers well. Where animal vaccine is used, the ivory 
slip or sharpened quill may also be used with satisfaction to make the 
scarification or erasion. Whatever instrument is used, it should always 
be kept perfectly clean. 

A point of vital importance is that which relates to the proper 



"Seaton, "Vaccination," ii Reynold's System of Medicine, vol. i, p. 291. 
Second edition. 



SMALL-POX. 405 

age at which children should be vaccinated. Ordinarily, vaccina- 
tion should be performed within the first six months of life. In time 
of danger from a threatened, or in the presence of an actual, epidemic, 
infants may be vaccinated when only one' day old. 

In order to secure permanent protection against small-pox, re- 
vaccination should be performed after a certain interval. Some place 
the period at which this second vaccination should be done at five 
years, while others allow a longer interval — seven, eight, or ten years. 
The law of Prussia is that every child that has not already had small- 
pox must be vaccinated within the first year of its life, and every 
pupil in a public or private institution is to be revaccinated during 
the year in which his or her twelfth birthday occurs. 

This law was passed in 1874. Prior to this time the mortality 
from small-pox was 15 to 20 per 100,000 of the population. Since 
the law was enacted the small-pox mortality has varied from 0.3 to 
3.6 per 10,000. Not a single death from small-pox occurred in the 
German army between 1874 and 1882. 14 

A re vaccination, even if successful, seldom passes through all the 
typical stages of a primary vaccination. The vesicle rarely becomes 
so full and plump, and is more frequently flat and irregular in outline. 
Swelling of the axillary glands and other complications also seem 
to be more frequent than in cases where the vaccination is done for 
the first time. 

The question whether the lymph direct from the cow or human- 
ized lymph is the more efficient has caused much discussion. The 
objections urged against the use of humanized virus are : first, that 
its protective power has become diminished by transmission through 
many generations ; second, that it is liable to transmit other diseases, 
such as syphilis, tuberculosis, scrofula, etc.; third, that it is fre- 
quently difficult to obtain in sufficient quantities in an emergency, 
such as an actual or threatened epidemic. 

The first objection is disproved by the testimony of many of the 
most distinguished medical men in Europe and this country. Hu- 
manized vaccine virus, when properly inoculated, seems to be as 
completely protective against small-pox as that taken direct from 
the animal. Among its advantages are, that it "takes" more readily 
and runs through its stages of development in a shorter time, and 
that it will retain its active properties for a greater length of time 
than animal virus. The physician can usually control the source 
whence he obtains it. He can watch over the subject that furnishes it 

14 Frolich, Militar-Medicin, p. 461. 



406 TEXT-BOOK OF HYGIENE. 

and reject that which is suspicious. With humanized lymph col- 
lected by the physician himself there can be no doubt as to its purity 
or age; with animal lymph furnished by the cultivators of that ar- 
ticle there can be no certainty about either of these important points. 

That syphilis has been inoculated with humanized virus can no 
longer be open to doubt. The recent experiment of Dr. Cory, of 
England, has settled this question definitely. With care, however, 
this sad accident can easily be avoided, and the fact that syphilis 
has been so rarely transmitted by vaccination is sufficient evidence that 
the danger of such infection is not very great. 

The most serious objection against the exclusive use of human- 
ized lymph, is, that in grave emergencies, such as a rapidly-spreading 
epidemic of small-pox, it is difficult to obtain a sufficient supply of 
the lymph. However, humanized virus can never be obtained under 
the same strict asepsis as prevails in the production of animal virus, 
and its employment is not justifiable on this account, if for no other 
reason. 

Humanized virus is inoculated, either in the fresh state, i.e., the 
lymph is taken directly from the vesicle on the seventh day and inoc- 
ulated directly into the arms of other individuals, or else the vesicle 
is allowed to dry into a crust, with which a thin paste is made by 
moistening with water at the time of vaccination. The readiest way 
of using the crust is to crush a small fragment between two small 
squares of glass, then moistening it with a drop of warm (not hot) 
water, and smearing it on the spot where the vaccination is to be made. 
With a lancet a number of cross-scarifications are then made, and the 
virus well rubbed in. Only so much of the crust should be moistened 
as will be used at the time. Particular care must be taken not to use 
saliva for moistening the crust. Aside from being unclean, there is 
danger of producing blood-poisoning by inoculating certain of the 
oral secretions. 15 

Animal virus is obtained by inoculating a calf or heifer with 
virus from another case of cow-pox, or by re-inoculating humanized 
vaccine virus into the animal. The vesicles are opened on the sev- 
enth day or at the end of ninety-six hours (Copemann) and ivory 
points or the ends of quills coated with the lymph and dried with a 
gentle heat, or the pulp is rubbed up with 50 per cent, glycerin and 
drawn up in fine glass tubes. The whole operation, from beginning 
to end, is done under strict asepsis. 

In vaccinating with animal virus, the quill or ivory point is first 

15 See Sternberg and Magnin, Bacteria, p. 355. Second edition. 



SMALL-POX. 407 

moistened with a drop of water to soften the adhering lymph; the 
scarification or abrasion of the skin is then made with the lancet or 
needle, and the virus rubbed well into the scarified spot, or, in using 
the glycerinized virus, the latter is simply rubbed into the scarified 
area. 

In using animal virus the successive stages of development are 
usually one or two days later than when humanized virus is used. 
In the former case the areola is rarely developed before the ninth day. 

Certain complications are likely to occur in the course of the 
vaccinia, of which the student should be aware. 

When the areola appears there is usually more or less fever. 
Sometimes the constitutional manifestations are decidedly marked, 
fever of a high grade being not uncommon. In addition to the 
glandular enlargement and tenderness, an outbreak of roseola some- 
times comes on about the ninth or tenth day. This eruption may be 
mistaken for scarlet fever, but if it is remembered that two infectious 
diseases rarely co-exist in one individual during their full develop- 
ment this error will be avoided. 

Erysipelas involving the entire arm is sometimes observed as a 
complication of vaccination. This, in nearly every case, depends upon 
some depravement of the patient's constitution, malnutrition, bad 
sanitary surroundings, or, perhaps, more frequently, chronic alco- 
holism. Individuals who are habitually intemperate in the indulgence 
of alcoholic liquors are especially unfavorable subjects for vaccination. 
The results are, fortunately, rarely serious to the patient. 

Another inconvenient complication of vaccination is the forma- 
tion of a deep, ill-looking, sloughing ulcer at the vaccinated point. 
This is the result of infection with impure virus or lack of cleanliness 
in making the scarification. It should be borne in mind that a very 
sore arm, especially if followed by the formation of an ulcer or gan- 
grenous sore, may not be protective against small-pox. Such a patient 
should not be considered properly vaccinated, and must be revaccin- 
ated as soon as he recovers, or immediately if there is any danger 
of small-pox infection. 

Children with eczematous eruptions, however, localized upon any 
portion of the body, should not be vaccinated until the eruption is first 
cured, except in times of danger from small-pox. The eczema will 
be almost certainly rendered worse in consequence of the general 
hyperemia accompanying the febrile reaction, and the physician who 
performs the vaccination will be blamed for causing the skin disease. 



408 TEXT-BOOK OF HYGIENE. 

The author has placed on record 10 two cases of general psoriasis 
following vaccination, and other cases have been since reported. 
Urticaria and exudative erythema have also been repeatedly observed. 

As before stated, syphilis may be communicated to the vaccinee 
by vaccine virus obtained from a syphilitic subject, but this acci- 
dent is infrequent. There can be little doubt that some of the cases 
reported as "vaccinal syphilis" are cases of tardy hereditary syphilis, 
lighted up by the general systemic disturbance following vaccination. 
In some cases tetanus has followed vaccination. This unfortunate 
coni2)lication may be due either to the tetanus bacilli gaining access 
to the virus in the process of preparation, or infection of the patient 
during vaccination. 

Xext in importance to vaccination in the prophylaxis of small- 
pox is prompt isolation of the sick. ~No one but the medical and other 
attendants of the sick should be allowed to come in contact with them. 
All attendants and other persons exposed to the infection should, 
of course, be promptly vaccinated, unless this has been successfully 
done within the previous year or two. Disinfection of all discharges 
from the patient and of the room and its contents, after the patient 
has recovered or died, must be practiced. The best disinfectants in 
small-pox are bichloride of mercury, free chlorine, sulphurous acid, 
and formaldehyde. 

"When it is learned that a person has small-pox, if he is not re- 
moved to a special hospital, a room should be prepared for his occu- 
pancy. The carpets should be taken up and the floor kept clean. 
Window-curtains and unnecessary furniture and drapery should be re- 
moved from the room. After recovery of the patient the bed-clothing 
must be thoroughly disinfected with steam or sulphurous acid, or de- 
stroyed by fire. The individual himself should not be allowed to 
mingle with healthy persons until all danger of infection is passed 
and the surface of his body has been thoroughly disinfected. 

At a conference of sanitary officials in the city of Chicago (May. 
1894) the following propositions were adopted. They represent the 
most advanced conclusions of competent authority upon the most 
practical means of limiting the spread of small-pox : — 

"1. The city should be divided into districts containing not more 
than 10,000 people. 

"2. Each district should be placed under the supervision of a 
competent medical inspector with necessary assistants to (a) make 
a house-to-house inspection; (b) to successfully vaccinate, within 

"Journal Cutaneous and Venous Diseases, vol. i, No. 1, p. 11. 



ASIATIC CHOLERA. 409 

the shortest possible time, all persons who have not been vaccinated 
during the outbreak, and that the first vaccination be within seven 
days; (c) to properly disinfect all houses and their contents where 
small-pox occurs. 

"3. Necessary means and appliances for efficient disinfection of 
materials, premises, etc., should be provided as the exigencies of each 
district may require. 

"4. Each case of small-pox should be immediately removed to a 
suitably constructed and properly equipped and officered isolation 
hospital. 

"5. Except in extreme cold weather, hospital tents, as prescribed 
in the United States Army Eegulations, floored and warmed, are pre- 
ferable to the average hospital or private dwelling, and increase the 
chances of recovery of the patients. Cases of small-pox necessarily 
detained in their own homes should, with their attendants, be rigidly 
isolated during the period of danger, and physicians visiting such 
patients professionally shall be subject to such regulations as may be 
prescribed by the local health officer. 

"6. Persons exposed to small-pox contagion should be immedi- 
ately vaccinated or revaccinated, and kept under observation for not 
less than fourteen days from time of last exposure. 

"7. It is the sense of this conference that where such measures 
are all enforced it will net be necessary for neighboring cities and 
states to exclude all persons who come from such city who are not 
protected against small-pox by vaccination, and to require disinfec- 
tion of all baggage and merchandise capable of conveying small-pox 
infection." 

ASIATIC CHOLERA. 

A disease which causes the death of three-fourths of a million of 
human beings where it is endemic within the space of five years, and 
which makes periodical excursions, spreading over nearly the entire 
inhabited globe with destructive violence, must surely command the 
interested attention of every intelligent person. Asiatic cholera is 
endemic in India, w 7 here it probably originated centuries ago. Some 
authors claim to have found satisfactory evidence of its existence in 
the writings of the classical authors of India and Greece at a period 
as early as the second century of the Christian era. The evidence is. 
however, not beyond question. In the sixteenth and seventeenth cen- 
turies European travelers in the East gave pretty exact accounts of 
the disease. One of the most definite of these was given by Caspar 
Correa, an officer in Vasco de Gamma's expedition to Calicut. He 



410 TEXT-BOOK OF HYGIENE. 

states that Zamorin, the chief of Calicut, lost 20,000 of his troops 
by the disease. A still more definite and the first trustworthy account 
is that of Sonnerat, a French traveler. He describes a pestilence hav- 
ing all the characters now recognized as belonging to Asiatic cholera, 
which prevailed in the neighborhood of Pondicherry and the Coro- 
mandel coast in 1768 and 1769, and which carried off 60,000 of those 
attacked by it within a year. Dr. McPherson, in his "History of 
Cholera/' gives numerous references which indisuptably establish the 
endemic existence of the disease in India prior to the present cen- 
tury. 

Being endemically prevalent over a greater or less area of India 
for many years, cholera finally, in 1817, crossed the boundaries of that 
country, and, advancing in a southeasterly direction, invaded Ceylon 
and the Sunda Islands in 1818. In a westerly direction the disease 
was carried to the islands of Mauritius and Eeunion, and reached the 
African coast in 1820. During this year it also traveled northeasterly, 
devasting the Chinese Empire for the two following years, reach- 
ing Nagasaki, in Japan, in 1822. 

In 1821 the disease spread from India in a westerly direction, 
extending along the east coast of Arabia to the border of Mesopotamia 
and Persia. In the spring of 1822 it began with renewed violence, 
following the river Tigris to Kurdistan, and, extending farther in a 
westerly direction, reached the Mediterranean coast of Syria. In 
the following year, 1823, it extended from Persia into Asiatic Eussia, 
reaching Astrachan on the European border in September, but dying 
out nearly everywhere beyond the borders of India during the ensuing 
winter. 

In 1826 cholera again advanced from India, reaching Orenburg 
in Eussia, in 1829, and in the following winter appeared in St. Peters- 
burg. Extending to the north and south, it invaded Finland and 
Poland the same year. From Persia the disease spread to Egypt and 
Palestine in 1830-31. 

From Eussia the pestilence invaded Germany in 1831, passing 
thence in 1832 into France, the British Isles, Belgium, the Nether- 
lands, Norway, and Sweden. In the latter year cholera crossed the 
Atlantic Ocean for the first time, being carried to Canada by emi- 
grants from Ireland, and spreading thence to the United States by 
way of Detroit. In the same year it was imported into New York by 
emigrants, and rapidly spread along the Atlantic coast. During the 
winter of 1832 it appeared at New Orleans, and passed thence up the 
Mississippi Valley. Extending into the Indian country, causing sad 



ASIATIC CHOLERA. 411 

havoc among the aborigines, it advanced westward until its further 
progress was stayed by the shores of the Pacific Ocean. In 1834 it 
reappeared on the east coast of the United States, but did not gain 
much headway, and in the following year New Orleans was again in- 
vaded by way of Cuba. It was imported into Mexico in 1833. In 
1835 it appeared for the first time in South America, being restricted, 
however, to a mild epidemic on the Guiana coast. 

While the pestilence was advancing in the Western Hemisphere, 
it also spread throughout Southern Europe, invading, in turn, Portu- 
gal, Spain, and Italy. 

Extending in an easterly direction from India, the disease reached 
China and Japan in 1830-31; westwardly, Africa was invaded in 
1834, and ravaged by the epidemic during the following three years. 

This second extensive outbreak of cholera ended in 1837, disap- 
pearing at all points beyond the borders of India. In 1846 the dis- 
ease again advanced beyond its natural confines, reaching Europe, 
by way of Turkey, in 1848. In the autumn of this year it also ap- 
peared in Great Britain, Belgium, the Netherlands, Sweden, and the 
United States, entering by way of New York and New Orleans. In 
the succeeding two years the entire extent of country east of the Eocky 
Mountains was invaded. During 1851 and 1852 the disease was fre- 
quently imported by emigrants, who were annually arriving in great 
numbers from the various infected countries of Europe. In 1853 and 
1854, cholera again prevailed extensively in this country, being, how- 
ever, traceable to renewed importation of infected material from 
abroad. In the following two years it also broke out in numerous 
South American States, where it prevailed at intervals until 1863. 

Hardly had this third great pandemic come to an end before the 
disease again advanced from the Ganges, spreading throughout India, 
and extending to China, Japan, and the East India Archipelago during 
the years 1863 to 1865. In the latter year it reached Europe by way 
of Malta and Marseilles. It rapidly spread over the Continent, and 
in 1866 was imported into this country by way of Halifax, New York, 
and New Orleans. This epidemic prevailed extensively in the West- 
ern States, but produced only slight ravages on the Atlantic coast, 
being kept in check by appropriate sanitary measures. In the same 
year (1866) the disease was also carried to South America, and in- 
vaded, for the first time, the States bordering on the Rio de la Plata 
and the Pacific coast of the Continent. 

While the epidemic was thus advancing westward from its home 
in India, it was at the same time spreading northwardly over the en- 



412 TEXT-BOOK OF HYGIENE. 

tire western part of Asia, and in a southeasterly direction over North- 
ern Africa. In the latter continent it prevailed from 1865 to 1869. 

Cholera never entirely disappeared in Eussia during the latter 
half of the sixth decade, and in 1870 it again broke out with vio- 
lence, carrying off a quarter of a million of the inhabitants before 
dying out in 1873. It spread from Eussia into Germany and France, 
and was imported, in 1873, into this country, entering by way of New 
Orleans and extending up the Mississippi Valley. None of the 
Atlantic-coast cities suffered from the epidemic in 1873, and since that 
year the United States have been entirely free from the disease, with 
the exception of a few imported cases in New York Harbor in 1887. 

In June, 1883, a new epidemic of cholera broke out in Egypt, 
where it raged with great violence. The disease first appeared in 
Damietta, near the outlet of the Suez Canal. It was unquestionably 
imported from India, probably Bombay, where it prevailed as ea?ly as 
the month of May. At the time of the outbreak in Damietta that 
city was overcrowded with people who had come to attend a great re- 
ligious fair and festival. It has been proven that pilgrims from Bom- 
bay were among the attendants at this fair. The epidemic came to 
an end in Egypt in the autumn of 1883. In the same year (1883) a 
small outbreak occurred in Marseilles, but intelligence of it was care- 
fully suppressed by the authorities. The disease does not seem to have 
spread from this centre, but in June of the following year cholera 
broke out in Toulon, having probably been imported in a transport 
ship returning from Tonquin. This outbreak was very violent and 
rapidly spread throughout Southern France, Italy, and Spain. After 
apparently dying out during the winter, it reappeared in the spring of 
1885 with renewed violence. The total number of cases in Spain alone 
in the latter year was over one-third of a million, with nearly 120,000 
deaths. 

In the summer of 1885 cholera also broke out in a virulent form 
in Japan, and, after a cessation during the following winter, recurred 
with increased fatality in 1886. In the latter year there were over 
100,000 deaths from the disease in that country. 

During 1886 and 1887 cholera continued in Southeastern Italy 
and in the Austrian dominions at the head of the Adriatic. A few 
cases occurred in France and Germany, but by stringent sanitary meas- 
ures an epidemic was averted. 

In November, 1886, cholera was carried to South America in an 
Italian ship, the "Perseo," bound from Genoa to Buenos Ayres. The 
disease rapidly spread in the Argentine Eepublic, and, crossing the 



ASIATIC CHOLERA. 413 

Andean range, invaded the Pacific coast of the South American con- 
tinent for the second time, reaching Chili and Bolivia and threatening 
Peru and Brazil. In Chili alone there were over 10,000 deaths in the 
first six months of 1887. The further progress of the epidemic was 
arrested and the entire Western Hemisphere is now free from the 
disease. 

From July to December, 1889, cholera prevailed with consider- 
able virulence in Mesopotamia. In 1890 it reappeared in Spain; in 
1892 in France and Germany, raging with great violence in Ham- 
burg. Nearly 8000 persons died from the disease in the latter city. 
Some cases were brought thence to New York, but the active sanitary 
measures taken were successful in preventing its further spread. 

This brief historical sketch of all the epidemics of cholera ob- 
served beyond the borders of India. demonstrates several facts: first, 
that the home or breeding-place of cholera is in India, especially the 
delta of the Ganges, whence it spreads at intervals throughout the 
world; second, that it always advances along the lines of travel of 
large bodies of human beings; and third, that it advances, by pre- 
ference, along water-routes. Exceptions undoubtedly occur, but the 
rule is a general one. The disease seems to spread with difficulty along 
the lines of railroad. When the disease has extended from New 
Orleans it has always been up the Mississippi Valley, expending its 
violence upon the river cities — Vicksburg, Memphis, St. Louis, and 
Cincinnati. 

Several factors must concur before there can be an epidemic of 
cholera. These are: first, the cholera poison; second, certain local 
conditions of air, soil, or water; and, third, individual predisposition. 
Without a concurrence of all these conditions no outbreak can occur. 
If, by any means, the co-existence of these three conditions can be 
prevented, cholera can be averted. The following are facts bearing 
upon this question: Cholera is communicated through the agency 
of a specific poison. This does not admit of doubt. The researches 
of Dr. Eobert Koch, of Germany, have established the fact that a 
micro-organism found in the intestinal discharges of cholera pa- 
tients and in the bodies of those dead with the disease is the active 
agent in propagating the malady. This organism, named by Koch 
the "comma bacillus," from its general resemblance to a comma, was 
first discovered by this eminent pathologist in the intestinal contents 
of cholera corpses in Egypt, in 1883, and in the following year more 
thoroughly studied in Calcutta, whither he had been sent by the 
German government to pursue his investigations. It has been dem- 



414 TEXT-BOOK OF HYGIENE. 

onstrated that this germ is always present in the discharges of cholera 
patients, and up to this time it has not been found in any other dis- 
ease. Experiments upon animals have also shown that cholera can 
be produced in the latter by introducing the germ into their bodies 
in various ways. The demonstration of the bacterial nature of 
cholera seems to be complete. 

While cholera cannot be regarded as personally contagious in the 
same sense or in the same degree as small-pox, there can be no doubt 
that it is spread only by the poison from other cases of the disease. 
Generally this disease is conveyed by water polluted by the dejections 
of cholera patients. The regularity of its march along routes by 
which the intercourse of human beings takes place, and always in 
connection with other cases of cholera, proves this. There is no un- 
doubted case on record where genuine cholera has been spontane- 
ously developed outside of India. 

That certain geological and perhaps meteorological conditions 
are necessary for the propagation or virulence of the poison of 
cholera is beyond dispute. Outbreaks usually take place during the 
summer or autumn, and nearly always partly or entirely die out dur- 
ing cold weather. Further, in nearly all epidemics, certain cities or 
towns, or portions of a town, into which persons sick with cholera are 
brought, and where the poison of the disease is thus imported, remain 
exempt from the effects of the epidemic. The inference to be drawn 
from this fact is that in such localities the local conditions are un- 
favorable to the development of the poisonous germ, and it becomes 
inert. 

In India all the local conditions favorable to the propagation of 
the cholera-germ are found. The filthy personal habits of the people, 
the overcrowding, the intense heat, the lack of sufficient, appropriate, 
or properly-prepared food, and the extensive pollution of the water- 
supply, all combine to produce the necessary conditions of develop- 
ment of the cause of cholera. These conditions, doubtless, to a con- 
siderable extent, give rise to that depression of the system which seems 
necessary to constitute the individual predisposition to become 
infected. 

Given, then, at any place, a number of persons of a lowered de- 
gree of vitality — that is to say, persons not capable of resisting unfa- 
vorable influences upon their health under unfavoring conditions; 
given conditions of climate, water, and soil more or less similar to 
those existing in India: only the introduction of the third factor, 
the cholera poison, is needed to cause an outbreak. In many cities 



ASIATIC CHOLERA. 415 

of this country and Europe, as proven by the epidemics in Toulon, 
Marseilles, Naples, and other cities of Italy and Spain, the condi- 
tions are present which would furnish the most favorable breeding- 
place for the cholera-germ if introduced. 

The dejections and vomited matters of cholera patients contain 
the active agent which produces the disease. The contagious prin- 
ciple contained in these excretions, the cholera-germ or "comma 
bacillus" discovered by Koch, may gain an entrance into the body 
through the drinking-water or through infected air. Probably both 
modes are equally competent channels of infection. The prevailing 
theory is that pollution of the drinking-water is the most frequent 
source of the rapid spread of the disease. A very striking instance 
of this occurred in London during the epidemic of 1854, which has 
already been referred to, 17 and during the cholera epidemic in Ham- 
burg in 1893. 

Another striking instance of the communication of cholera by 
polluted water has been reported by Mr. John Simon, long the chief 
medical officer of the English "Local Government Board." The 
facts are as follow: The Lambeth Water Company drew its supply 
from the Thames, at Ditton, above the influence of the London sew- 
age and the tidal flux. The Southwark and Vauxhall Company drew 
its supply from the river near Vauxhall and Chelsea. The water of 
the Lambeth Company was tolerably pure, and that of the South- 
wark and Vauxhall Company was very impure. The water of both 
companies was distributed in the same district at the same time and 
among the same class of people, the pipes of the two companies being 
laid pretty evenly in the same areas, in many places running side 
by side in the same streets, and the houses supplied being pretty 
equally distributed. The deaths from cholera in the houses supplied 
by the Lambeth Company were at the rate of 37, and in the houses 
supplied by the Southwark and Vauxhall Company at the rate of 
130, to every 10,000 persons living. It appears, therefore, that of 
the drinkers of the foul water about three and a half times as many 
as those who drank the pure water died of cholera. 

In addition to the influence of polluted drinking-water in spread- 
ing cholera, must be mentioned articles of food contaminated with 
the infectious matter of the disease. It is also no longer open to 
question that persons may become infected by handling the clothing 
and bedding of cholera patients. Laundresses are in special danger 
from this source. 



w See ante, page 64. 



410 TEXT-BOOK OF HYGIENE. 

The prophylaxis against cholera comprises such measures as will 
prevent the admission of the cholera-poison into a community, arrest 
the development of the poison after its introduction, and reduce the 
individual susceptibility to attack. 

It is evident from the foregoing that if the introduction of the 
cholera-poison could be prevented no outbreak of the disease could 
occur. With this in view, some have urged the enforcement of a strict 
policy of non-intercourse with the infected localities. But at the 
present day few sanitarians advocate these extreme measures. A 
modified system of restricted intercourse is supported by many au- 
thorities, who claim that by the adoption of a thorough system of 
maritime inspection, disinfection, and observation — a rational quar- 
antine, in fact — the poison can be rendered ineffective or its entrance 
into a community prevented. 

The best authorities, however, think that it is not only easier, but 
far more effective to place the threatened locality in such a sanitary 
condition that the development of the cholera-poison cannot take 
place. The contrast between the effectiveness of quarantine and local 
sanitation as safeguards against cholera has been well expressed by 
von Pettenkofer, who compares cholera epidemics to powder explo- 
sions. The virus of cholera, he says, is the spark that evades the 
strictest quarantine; the powder is the ensemble of local conditions 
which predispose to the outbreak. "It is wiser, therefore, to seek 
out and remove the powder than to run after and try to extinguish 
each individual spark before it drops upon a mass of powder, and, 
igniting it, causes an explosion which blows us into the air with our 
extinguishers in our hands." 

The measures of sanitation to be enforced are such as will se- 
cure cleanliness of person, of habitation and surroundings, of air, 
of water, and of soil. Pollution of the soil should be especially 
guarded against, for a polluted soil means impure air and water, and 
these mean, if not an infectious disease, at least a heightened recep- 
tivity to its influence. The quality of the drinking-water used must 
be above suspicion of contamination by the poison. Unless the latter 
ban be positively excluded, all drinking-water should first be boiled. 
It may then be cooled by pure ice. 

The individual predisposition to cholera is best guarded against 
by keeping the body clean and well nourished, and the mind free from 
worry. Underfeeding, anxiety, overwork, exposure to extremes of 
temperature, intemperance in eating and drinking should all be 



ASIATIC CHOLERA. 417 

avoided, as they tend to reduce the resistance of the system to the 
influence of the morbid poison. 

Certain measures of personal prophylaxis which have proven 
useful heretofore should be adopted wherever cholera prevails. One 
of the best of these is the use of sulphuric-acid lemonade as a drink. 
Ten to 15 drops of dilute sulphuric acid in a glass of water, sweet- 
ened with sugar, may be drunk instead of water. Experience with 
it during the epidemic of 1866 has demonstrated its great value as 
a preventive of cholera. The later researches of Koch have also 
shown that the "comma bacillus," or spirillum, cannot live in acid 
solutions. Hence, it is probable that if the contents of the stomach 
were always kept acid no infection could occur through absorption 
from the stomach. 

A painless diarrhea, called cholerine, attacks many persons dur- 
ing cholera epidemics. This disorder is easily curable if promptly 
attended to, but if allowed to run on it may develop into a malig- 
nant attack of cholera. 

Among the means of securing prompt treatment of the poorer 
classes in times of epidemics is the establishment of numerous public 
dispensaries, where medical aid can always be obtained. The estab- 
lishment of such dispensaries and, if possible, of temporary hospitals 
in the crowded portions of cities is a very important part of the 
prophylactic treatment. 

Inasmuch as it seems definitely established that the discharges 
from the stomach and intestines are the active agents in propagating 
the disease, the immediate disinfection of such discharges is vitally 
important. The stools and vomited matters must be rendered in- 
nocuous by germicidal agents, such as mercuric chloride, carbolic 
acid, or chloride of lime. 

Clothing and bedding should be disinfected with superheated 
steam, thorough boiling, or fumigation with sulphur dioxide or 
chlorine. Infected articles of this kind should not be sent to a 
laundry until they have been thoroughly disinfected by one of the 
above-mentioned means. 

Apartments which have been occupied by cholera patients should 
be thoroughly disinfected before being re-occupied, and afterward 
freely exposed to the air by opening doors and windows. The walls 
may also be washed with a solution of mercuric chloride. 

The most efficient disinfectant is mercuric chloride in the pro- 
portion of 1" part in 2000 of the material to be disinfected. The 
readiest way of securing disinfection with this agent is to add a 

21 



41 S TEXT-BOOK OF HYGIENE. 

solution of 1 to 1000 to an equal proportion of the discharges to be 
rendered innocuous. The mercuric chloride acts slowly, and hence 
the infected material should be exposed to the action of the disin- 
fecting agent for at least two hours before it can safely be thrown 
into sewers or cess-pools. 

There are several serious objections to the indiscriminate use of 
mercuric chloride by the public as a disinfectant. In the first place, 
it is intensely poisonous, and its perfectly transparent and inodorous 
solution might be readily accidentally drunk and cause fatal results. 
To reduce this danger, the Committee on Disinfectants of the Amer- 
ican Public Health Association recommended the addition of perman- 
ganate of potash or of sulphate of copper (blue vitriol) to color the 
solution. Another serious objection to mercuric chloride is that it 
cannot be used where the disinfected material must pass through lead 
pipe, as this is rapidly corroded by the sublimate. In many water- 
closets it cannot therefore be used. 

Chloride of lime (bleaching powder) has been found to be a very 
rapid and efficient disinfectant, as well as a deodorizer; but the 
chlorine, upon which its effectiveness depends, is often so deficient in 
proportion, and the compound so readily deteriorates that, unless a 
preparation can be obtained that contains at least 25 per cent, of 
available chlorine, it may prove injurious by causing a false sense of 
security. A trustworthy preparation may be dissolved in water, when 
required, in the proportion of 1 to 100. An objection to its use is the 
pungent odor of chlorine, which is very offensive to many persons. 

Dr. Koch recommends carbolic acid, which he has shown will 
kill the "comma bacilli" in a dilution of 1 to 20 of water. The or- 
dinary preparations of carbolic acid sold as disinfectants are, how- 
ever, not to be relied on, many of them not containing more than 2 
per cent, of the acid. Further dilution of these agents would alto- 
gether destroy their disinfecting power. The purer article is, on the 
other hand, too expensive to be used as a disinfectant. 

Little's soluble phenyle is an efficient disinfectant in the pro- 
portion of 2 per cent. (1 to 50). It is furnished of uniform strength, 
is moderately cheap, non-poisonous, and readily miscible with water. 
In addition to its disinfecting power, it is also an excellent deodor- 
izer, promptly removing all odors of decomposition and putrefaction. 
Its only objection is a rather pungent although not unpleasant odor, 
which somewhat resembles creasote. 

In the very beginning of an epidemic, prompt isolation of the 
sick and thorough disinfection of the surroundings of the patient 



RELAPSING FEVER. 419 

may check the spread of the disease. Much cannot be expected from 
these measures, however, unless the local sanitary conditions are such 
as offer a hindrance to the development of the cholera-poison. It is 
plain, therefore, that prophylactic measures against cholera, to be 
effective, must be brought into requisition before the epidemic has 
begun. After the outbreak of the disease it may be too late to put the 
threatened locality in a good sanitary condition. It is of the highest 
importance that preventive measures be enforced early. Above all, 
the purity of the drinking-water must be safeguarded. 

RELAPSING FEVER. 

Eelapsing fever was first clearly described by Dr. John Eutty, 
in his "Chronological History of the Weather, Seasons, and Diseases 
of Dublin from 1725 to 1765." 18 During the last century relapsing 




Fig. 44. — Spirochseta Obermeieri. X 380. 

fever was frequently met with in epidemic form in Ireland and Scot- 
land. In 1847 the disease invaded a number of the larger cities of 
England. From 1868 to 1873 it prevailed extensively in England 
and Scotland. On the continent of Europe it was first observed in 
Eussia in 1833. In Germany it was not recognized as a distinct 
disease until 1847, but did not prevail epidemically until 1868. Since 
then it has often been observed in that country. 



18 London, 1770. 



420 TEXT-BOOK OF HYGIENE. 

Relapsing fever is very prevalent in India, where it was first 
observed in 1856 by Sutherland. In China and -in the countries of 
Africa bordering on the Red Sea the disease has been recognized by 
observers. 

In the United States it was first observed among emigrants in 
Philadelphia in 1844, and again in 1869. It was conveyed to other 
places, but has never prevailed extensively in this country. It has 
not been observed in the United States since 1871. 

The predisposing causes of relapsing fever are, above all, bad 
sanitary surroundings. Want and overcrowding seem to be much less 
important factors than in typhus fever. 

Although relapsing fever has, since it was first clearly distin- 
guished from typhus and other continued fevers, been recognized as 
an eminently contagious and infectious disease, it was not until 1873 
that its immediate cause became known. In that year Obermeier dis- 
covered in the blood of patients ill with this disease a minute, spiral, 
mobile organism, now known as the spirillum or Spirochete Ober- 
meier i. (Fig. 44.) 

Obermeier and other observers, prominent among whom is Dr. 
Henry V. Carter, have demonstrated the constant presence of these 
organisms in the blood during the attack. Carter and Koch have 
induced the disease in monkeys by inoculation of the parasite, and 
Moschutkowski has successfully inoculated it in the human subject. 
Xo doubt can exist at the present day that the spirillum of Obermeier 
is the true cause of relapsing fever. 

The preventive measures consist in attention to details of per- 
sonal hygiene ; in other words, local sanitation, disinfection of in- 
fected materials (fomites), and complete isolation of the sick. 

TYPHOID FEVER. 

The first accurate clinical accounts of typhoid fever date from 
the seventeenth century, when Baglivi, Willis, Sydenham, and others 
described cases of fever which in their clinical characters corres- 
pond to the disease now known as typhoid fever. Strother, however, 
in 1729, first gave a description of the anatomical characters of the 
disease, which he saj^s is a 'Vymptomatical fever, arising from an 
inflammation, or an ulcer, fixed on some of the bowels." Bretonneau 
and Louis, in France; Hiklenbrand, in Germany; William Jenner, 
in England ; and Drs. Gerhard and Pennock, in this country, clearly 
pointed out the essential distinction between typhoid and other fevers. 

At the present day typhoid fever is met with everywhere through- 



TYPHOID FEVER. 



421 



out the world. It is at nearly all times a constituent of mortality 
tables. It affects by preference persons between the ages of 15 and 
30 years, although no age is entirely exempt. It is always more 
prevalent in the autumn and winter. 

The disease is due to a micro-organism which gains entrance into 
the body through the digestive tract. The micro-organism was first 
observed by Eberth and Gaffky, and is termed bacillus typhosus. It 
is found in the intestinal canal, and especially in the characteristic 
intestinal lesions of this fever. It is contained in the dejections of 
patients. The disease is not immediately contagious, like typhus 
fever. 




Fig. 45. — Pure Culture of Typhoid Bacilli, showing Clumping when 

Brought in Contact with Blood from Typhoid Patients. 

(Widal reaction.) 

The medium through which the poison is introduced into the 
body may be drinking-water, food, milk, or other articles containing 
the infective agent. Localized epidemics due to infected water, milk, 
and oysters have been frequently reported. 19 

At present the evidence is in favor of the view that cases of 
typhoid fever are always derived from pre-existing cases. The germ 
may exist in sewage and be carried from place to place; it may be 
carried into the soil from cess-pools receiving typhoid dejections, and 
thus gain access into wells and pollute the drinking-water. By the 
admixture of such water with milk or other food the disease may 
be propagated. The germs are frequently carried by flies. 

The prophylactic measures against typhoid fever comprise iso- 



19 See ante, pp. 61-64. 



4-2-2 TEXT-BOOK OF HYGIENE. 

lation of the sick, prompt disinfection of the discharges, and cleanli- 
ness in the widest sense. The water- and food- supplies must be 
carefully guarded against contamination with the bacillus, excreta 
must be removed from the immediate vicinity of dwellings. The 
requisites for prevention may be summed up as pure air, pure water, 
uncontaminated food, and a clean soil. 

TYPHUS FEVER. 

Wide-spread pestilences are nearly always accompaniments of 
famine and war. Of all pestilential diseases, none is so regular in 
its coincidence with these conditions as typhus fever. The earliest 
accounts which unquestionably refer to this disease date from the 
eleventh century, when it was observed at a number of places in Italy. 
In the succeeding centuries isolated accounts of it appeared in the 
chronicles of the times, but no scientific description of it appeared 
until the sixteenth century. During the seventeenth, eighteenth, and 
the early part of the nineteenth centuries it prevailed extensively 
throughout Europe. The constant wars and consequent disturbances 
of the social relations of the people, famines, overcrowding, filth, 
excesses of all kinds, contributed largely to the development and 
spread of typhus fever. For a number of years past no extensive 
epidemic of the disease has been observed, although in this country 
and in Europe localized outbreaks are frequently met with. 

Typhus fever is somewhat more prevalent in the winter and 
early spring months than during the rest of the year, but not very 
markedly so. 

At present, typhus fever is nearly always limited to times and 
places where the conditions favoring its development exist. Wherever 
overcrowding, in connection with filth, insufficient food, and bad 
habits are present, typhus fever is likely to be a visitor. Thus, in 
overcrowded and ill- ventilated emigrant ships, in jails and work- 
houses, and in camps, especially when stress of weather compels the 
crowding together of soldiers in close huts or barracks, the disease 
frequently breaks out. 

When typhus appears in a community, those classes of the 
people who are subjected to the conditions just mentioned are almost 
exclusively attacked. In cities, the dwellers in crowded tenements, 
or in courts and alleys, suffer most severely — are, in fact, almost the 
only ones attacked. An exception must, however, be made in the case 
of hospital physicians and attendants where typhus-fever patients are 
treated. The mortality among these is always large. 



YELLOW FEVER. 423 

Typhus fever is contagious and infectious. The cause is un- 
known. An exposure for a length of time to an atmosphere impreg- 
nated with the poison may suffice . to induce an attack. The poison 
may also be conveyed from place to place in fomites. Physicians may 
carry it in their clothing, if they have been exposed to typhus atmos- 
phere. 

The prevention of typhus fever consists in the institution of such 
measures as will secure pure air, pure water, a clean soil and dwell- 
ings, and cleanliness of body and clothing. When an outbreak occurs, 
the sick should be promptly isolated, the well persons removed from 
the building in which the cases have occurred, and efficient measures 
of disinfection carried out. The sick should be treated in the open 
air as much as possible. 

YELLOW FEVER. 

The West India Islands, the Gulf coast of Mexico, the northern 
part of the Atlantic coast of South America, and a limited section of 
the west coast of Africa constitute the present home of yellow fever. 
From this area (the so-called "yellow-fever zone") the disease is fre- 
quently transported to contiguous or distant countries. The South 
Atlantic and Gulf coasts of the United States and the shores of the 
Caribbean Sea are the most liable to the epidemic visitation of this 
pestilence. 

The first trustworthy account of an epidemic of yellow fever 
dates from the year 1635, when it prevailed on the Island of Guade- 
loupe. This and the adjoining islands of Dominica, Martinique, and 
Barbadoes were invaded a number of times in the fifty years follow- 
ing the above date. Jamaica was invaded in 1G55 and Domingo the 
year after. In 1693 the first appearance of the disease is mentioned 
in the United States, being observed in Boston, Philadelphia, and 
Charleston. In 1699 it appeared as an epidemic in Vera Cruz, and 
re-appeared in Philadelphia and Charleston. Since the year 1700, the 
disease has appeared in an epidemic form, at one or more places within 
the present limits of the United States, eighty times, the last con- 
siderable invasion being at Jacksonville and other places in Florida, 
and Decatur, in Alabama, in 1888, and to a lesser extent in New 
Orleans in 1903. It has also been endemic in Cuba until recent 
years. 

In South America yellow fever appeared for the first time in 
1740. In 1849 the disease was imported into Brazil, and has since 



424 TEXT-BOOK OF HYGIENE. 

then been endemic. Peru and the Argentine Republic have also suf- 
fered several severe visitations of yellow fever since 1854. 

On the west coast of Africa, yellow fever seems to be endemic 
in the peninsula of Sierra Leone, where it has been frequently ob- 
served since 1816. It has also prevailed epidemically in Senegambia 
and a number of the islands off the northern portion of the west 
African coast. In Europe, Spain and Portugal have been the only 
countries to suffer from yellow-fever epidemics. 

Although the causes of yellow fever cannot be definitely stated, it 
is well known that it only occurs endemically within the tropics, and 
prevails epidemically elsewhere only during the summer. Of 180 epi- 
demics observed in the United States and Bermudas, 154 began in 
July, August, and September. Of the remaining 26, none began in 
the six months from November to April. 

A temperature of 26° C. and a high humidity are generally con- 
sidered essential to produce an outbreak of the disease. Of other 
necessary meteorological conditions nothing is known. 

That the specific cause of yellow fever is a micro-organism ap- 
pears probable from a consideration of the clinical history of the 
disease and its mode of propagation. Up to the present time, how- 
ever, none of the various organisms described as causative have made 
good the claims advanced by their discoverers. Surgeon-General 
Sternberg has shown that neither the organism of Freire, of Car- 
mona, of Babes, of F. S. Billings, of Finlay, or of Oibier is the true 
cause of yellow fever. 

It seems to be well established that the most filthy and insani- 
tary portions of cities are those principally ravaged by yellow fever. 
It has also been firmly established that the disease is propagated 
through the agency of a certain species of mosquito (stegomyia fasci- 
ata), the latter acting as an intermediate host. 

Yellow fever is not endemic within the limits of the United 
States, and has probably never originated here. The instances in 
which it has appeared to do so may be explained by the persistence of 
the morbific agent through one or more winters, or by a new importa- 
tion which has escaped observation. 

Yellow fever frequently breaks out on shipboard and causes much 
loss of life. There is no evidence that it originates on ships; it is only 
acquired after intercourse with an infected ship or infected place. 

The question of personal contagion of yellow fever has been 
decided negatively. The disease is infectious, but persons sick with 



SCARLET FEVER AND MEASLES. 425 

the disease do not communicate it, the disease being communicated 
from the sick to the well by the bites of infected mosquitoes. 

The preventive measures indicated against yellow fever appear 
from the foregoing : they are strict sanitary inspection to prevent the 
introduction of a person sick with the disease; to prevent the mos- 
quitoes from coming in contact with yellow fever patients; and to 
employ such measures as would lead to the extermination of 
mosquitoes. 

When the disease becomes epidemic in a city, the inhabitants 
should be removed to temporary camps beyond the infected area. The 
experience of the city of Memphis in 1879, and that of various locali- 
ties in Florida in 1888, New Orleans, and especially Cuba, encour- 
ages the hope that by prompt isolation of the sick and strict enforce- 
ment of sanitary measures with especial reference to mosquitoes, the 
terrors of yellow fever can be largely averted. The sick should be 
promptly isolated, and protected by screening. 

SCARLET FEVER AND MEASLES. 

The early history of these two contagious eruptive fevers is in- 
extricably blended together. Up to the latter half of the seventeenth 
century the distinction between the two was not made by writers. 
Sydenham was among the first who clearly separated scarlet fever 
from measles and gave it a distinct name. Since the Great English 
Hippocrates, the essential character of scarlet fever has been recog- 
nized by all physicians, and now it is never, or but rarely, confounded 
with measles. 

Of the two diseases, measles is somewhat more generally preva- 
lent, although both occur usually in epidemics. There is hardly a 
country in which measles has not been observed, while the continents 
of Asia and Africa have remained measurably exempt from scarlet 
fever up to the present time, although epidemics have been recorded 
in India and Japan. 

Hirsch states that scarlet fever was first observed in this country 
in 1735, at Kingston, Mass., quoting as authorities Dr. Douglass, of 
Boston, and Dr. Colden, of New York. The latter, however, in a 
letter to Dr. Fothergill, 20 clearly describes diphtheria, and not scar- 
let fever. Its distribution is now general, but it is said to be much 
milder in the southern than in other portions of the United States. 
The prevalence of measles is not limited to any geographical section. 

20 Medical Observations and Inquiries, vol. i, p. 221. London, 1776. 



426 TEXT-BOOK OF HYGIENE. 

Epidemics of -measles usually begin during cold weafher. Of 
530 epidemics observed in Europe and North America, 339 occurred 
during the colder and 191 during the warmer months. In 213 of 
these, the height of the epidemic occurred 135 times in winter and 
spring, and only 78 times during summer and autumn. Scarlet fever 
epidemics occur more frequently in autumn than at any other season. 

The cause of scarlet fever or of measles is not to be sought in 
climatic influences, insanitary surroundings, or special natural con- 
ditions of air, water, or soil. Both diseases are contagious and infec- 
tious, and the contagion is transmitted either by fomites (clothing, 
letters, etc.), infected air, drinking-water, or milk. 

Several observers have claimed the discovery of the specific or- 
ganism of scarlet fever, but no trustworthy evidence has yet been fur- 
nished that the problem is solved. On a previous page reference has 
been made to the probable connection between a disease of milk-cattle 
and scarlet fever. 

The measures for the prevention of both diseases are isolation 
and thorough disinfection. 

DIPHTHERIA. 

Under the names of Syriac and Egyptian ulcers, Aretgeus, a 
writer of the second century, described various forms of malignant 
sore throat. The disease now called diphtheria prevailed at various 
places in Europe during the Middle Ages. In this country it was 
first observed about the middle of the last century, and in 1771 Dr. 
Samuel Bard, of New York, described it very accurately. Although 
repeated severe outbreaks occurred in Europe in the early part of the 
present century, it was not until 1857 that it again attracted attention 
by its epidemic prevalence in the United States. Since that time 
it has spread throughout the country, and is at present one of the most 
generally diffused, as well as one of the most fatal, of the contagious 
diseases. In certain epidemics its malignancy is very marked, while 
in others it seems to be a rather mild affection. 

Diphtheria is personally contagious. The infecting agent is a 
micro-organism first described by Lofner. The bacillus can be dem- 
onstrated in the secretions from the throat or nose of diphtheria 
patients. The diphtheria bacillus may also be present in the throats 
of healthy individuals who are at the time insusceptible to the dis- 
ease, but are nevertheless carriers of the infection. 

The question as to the identity of diphtheria and croup is not 



DIPHTHERIA. 427 

merely a clinical one, but has an important bearing upon preventive 
medicine. If croup is a non-contagious and non-infectious disease 
no precautions will be necessary to prevent its spread to healthy 
persons. If, on the other hand, diphtheria and croup are identical 
in nature, the danger of infection is equally great in both diseases. 
With the evidence furnished by the bacteriologist before us, we can 
have no further doubt as to the identity of the two diseases. 

Diphtheria is inoculable upon animals, and may through this 
medium be transmitted to man. 

Persons sick with diphtheria should be carefully isolated; no 
one but the immediate attendants should be allowed to come in con- 
tact with the patients. Table utensils, bedding, and clothing used by 
the sick should be thoroughly disinfected by steam or boiling water 
before being used by others. Intimate contact with the sick, such as 




Fig. 46. — Diphtheria Bacilli. (Park.) 

kissing, should be strictly prohibited. There seems no room for 
doubt that the diphtheria bacillus can also be carried in the clothing. 
Hence, physicians and nurses should be especially careful in person- 
ally disinfecting themselves after contact with a case of diphtheria. 
After death or recovery of the patient, the apartment occupied during 
the illness should be disinfected. 

Children recovering from diphtheria, scarlet fever, measles, or 
small-pox, should not be permitted to attend school for at least four 
weeks after recovery. It is believed that there is danger of infection 
for a period about as long as this, and, besides, the patients are apt 
to be weakened from the effects of the disease, and not able to resist 
the strain of continuous mental effort. The safest plan is to main- 
tain quarantine until two successive cultures from the throat show 
absence of diphtheria bacilli. 



428 TEXT-BOOK OF HYGIENE. 

DENGUE. 

The disease known as break-bone fever, dandy fever, and by vari- 
ous other names, was first discovered in the United States in 1780, 
by Dr. Benjamin Rush. Dr. Rush describes an epidemic which pre- 
vailed during the summer and early autumn of that year under the 
name of "bilious remittent fever," but the symptoms of the disease 
hardly leave any doubt that it was dengue. In 1779 and 1780 it was 
also observed on the Coromandel coast, in Egypt, and on the island 
of Java. In 1784 to 1788 dengue also prevailed in various cities of 
Spain. In 1818 an epidemic appeared in Lima, in which nearly every 
one of the 70,000 inhabitants was attacked. 

In 1824-25 the disease again prevailed widely in India, where 
it was known as the "three-day fever." Isolated outbreaks occurred 
in that country until 1853, when it again appeared as a wide-spread 
epidemic, and in 1872 another epidemic outbreak occurred in the East, 
extending from Eastern Africa to Arabia, India, and China. 

In 1826 an epidemic of dengue appeared in Savanah, and in the 
following two years spread over the southern portion of the United 
States and the West Indies, reaching the northern coast of South 
America. In 1845 to 1849 the disease was observed in Rio Janeiro; 
in 1848 to 1850 in the South Atlantic and Gulf States. In 1854 it 
was observed in Southern Alabama, and in the same year in the West 
Indies. In 1873 another epidemic appeared in the lower Mississippi 
Valley, and in 1880 an outbreak of some extent occurred in New Or- 
leans, Charleston, and other places on the Gulf and South Atlantic 
coasts. 

Dengue always begins in the summer or early autumn, and ceases 
abruptly with the advent of cold weather. It is almost exclusively 
limited to hot countries. It spreads with extreme rapidity wherever 
it appears. It is not contagious; the manner of its propagation is 
not known. The susceptibility to the disease appears to be almost 
universal; it frequently prostrates the majority of the inhabitants 
where an outbreak occurs. During the epidemic in Calcutta in 1871- 
72, 75 per cent, of the population were attacked. In the United 
States similar epidemics have been repeatedly observed. 

Dengue is rarely fatal. It seems to be propagated through the 
atmosphere. No measures of prevention are known or available. 

EPIDEMIC INFLUENZA. 

Accounts of epidemic influenza can be traced back to the year 
1173, when the disease was observed coincidently in Italy, Germany, 



EPIDEMIC INFLUENZA. 429 

and England. It has prevailed epidemically, at varying intervals, to 
the present time. In the fourteenth century 3 epidemics are recorded ; 
in the fifteenth, 4; in the sixteenth, 7; in the seventeenth, 46. Of 
these, 15 were very extensive, some of them prevailing over both hemi- 
spheres contemporaneously. 

On the American continent influenza was first recorded in 1627, 
when it prevailed in New England, where it again broke out in 1625. 
Following this there is no notice of the disease in America until 1732, 
when an epidemic began in the New England States, which extended 
over the entire globe. Epidemics occurred during the remainder of 
the eighteenth century in 1737, 1757, 1761, 1767, 1772, 1781, 1789, 
and 1798. During the present century the disease has prevailed more 
or less extensively in this country at thirteen different times, the last 
epidemic of any considerable extent being in 1897. 

In November, 1889, an epidemic began in Russia which rapidly 
spread throughout Northern Europe, reaching the United States 
about the beginning of 1890, recurring in 1891 and 1892. The epi- 
demic was complicated in many cases by pneumonia of a fatal char- 
acter. The disease manifested itself in two principal forms, the 
catarrhal and the nervous. Epidemics more or less severe in char- 
acter have occurred since. 

A curious feature of epidemics of influenza is the coincident oc- 
currence of outbreaks of a somewhat similar affection among ani- 
mals, horses and dogs being especially attacked. 

Influenza is an acute, specific, infectious disease, not directly con- 
tagious. It is caused by a very minute bacillus first observed by 
Pfeiffer. The disease frequently appears over a large area of country 
almost simultaneously. Peculiarities of climate, season, meteorological 
conditions, geological formation, or racial characteristics have no ap- 
parent influence upon the causation or spread of the disease. It oc- 
curs more frequently in the winter and spring than during the summer 
or autumnal months. The investigation into the epidemic of influ- 
enza among horses, referred to in a previous chapter, 21 seems to 
indicate, however, that a moist and impure atmosphere intensifies the 
disease. 

No measures of prophylaxis can be indicated except avoidance of 
anything tending to depress the vital powers, as well as disinfection 
of the upper respiratory passages by the use of local antiseptics. 



Chapter I, p. 29. 



430 TEXT-BOOK OF HYGIENE. 

EPIDEMIC CEREBRO=SPINAL MENINGITIS. 

This disease was first recognized in Geneva in 1805. In the fol- 
lowing year it was noted in various places in the United States. Both 
in Europe and in this country localized outbreaks of the disease 
occurred between the dates above mentioned and 1816. At this time 
the disease seemed to die out altogether, but in 1822 it re-appeared in 
various parts of Europe and America. 

Cerebro-spinal meningitis appeared in 1857 in the southwest of 
France, and during the following ten years spread over a large part of 
the country. Algiers, Italy, Denmark, and Ireland were also visited 
by the scourge. In 1854 and 1861 Sweden experienced its ravages, 
and in 1859 Norway was invaded by the disease, which continued 
for nearly a decennium in the latter country. From 1860 to 1867 
the disease prevailed in Holland, Portugal, Germany, Ireland, and 
Eussia. 

After the termination of what may be called the first epidemic, 
in 1816, cerebro-spinal meningitis was not again observed in this 
country until 1842. In the eight years succeeding, it prevailed epi- 
demically throughout almost the whole United States. From 1861 
to 1873 it was noted frequently in various parts of the country. 
Since the latter year the reports of its occurrence in this country have 
been limited to sporadic cases or localized outbreaks. 

Cerebro-spinal meningitis is an acute infectious disease, very 
fatal in its tendency. It is contagious. The disease is caused by a 
diplococcus discovered by Weichselbaum (Diplococcus intracellulars 
meningitidis). Climate has no influence upon its origin, but season 
seems to stand in a positive relation to its causation. About three- 
fourths of the epidemics noticed have occurred during the winter and 
spring months. The disease seems to show no preference for peculi- 
arities of topographical or geographical formation. Overcrowding, 
overwork, and uncleanliness have an important influence in determin- 
ing an outbreak. It is especially a disease of youth and adolescence. 
Out of 975 cases occurring in New York only 150 were over 20 years 
of age, while of the remainder 665 were under 10. 

The prophylactic measures to be adopted against cerebro-spinal 
meningitis consist in careful attention to the sanitary conditions of 
dwellings and streets, avoidance of overwork and overcrowding dur- 
ing times of epidemic, isolation of the sick, and disinfection of the 
sick-room after the termination of the disease. 



SYPHILIS. 431 



SYPHILIS. 



In the year 1494, Charles VIII of France, in command of a 
large army, invaded Italy, and early in the following year besieged 
Naples. During the investment of the city a very severe disease, 
characterized by ulcers on the genitals, violent pains in the head and 
limbs, and generalized cutaneous eruptions broke out among the be- 
siegers and spread rapidly throughout the army and civil population. 
On the return of the army to France, after the termination of the 
war, the disease rapidly spread throughout Europe, and the literature 
of the early part of the sixteenth century, both medical and lay, teems 
with references to it. 

From the locality and other circumstances connected with its 
epidemic appearance the disease acquired various names. Thus, the 
French called it morbus Neapolitanus, or mat d'ltalie, while the 
Italians termed it morbus Gallicus, or mala Franzos. At a very early 
period it was, however, clearly recognized that the disease was com- 
municated during sexual intercourse, and hence it was usually de- 
scribed in medical writings under the name lues venerea, while in the 
popular literature it still figured as the Frenchman's disease {morbus 
Gallicus) . The name syphilis was first used in a poem descriptive of 
the disease, written in 1521 by Fracastor, a physician of Verona. 

The extraordinary outbreak of the disease toward the end of the 
fifteenth century led to many speculations concerning its origin. 
As it attacked persons in all ranks and conditions of life, "sparing 
neither crown nor cross," in the words of a contemporary poet, the 
favorite explanation was that meteorological influences had much to 
do with its causation. Many ascribed it to the malign influence of 
the stars. The Neapolitans attributed it to the wickedness of their 
enemies, the French, while the latter laid the blame on the filth and 
immorality of the Italians. The Spaniards claimed that it had been 
imported from America by Columbus, whose first expedition re- 
turned to Europe in 1493. There are records, however, which prove 
that the disease already existed in Italy in the latter year. In other 
parts of Europe the Jews, who had been driven out of Spain by the 
terrors of the Inquisition, were accused of this, as of many other 
misfortunes which befell the people. When it was definitely estab- 
lished that the disease was communicated almost solely by sexual 
intercourse, the theory of its transatlantic origin became very popular. 
It is characteristic of human nature to refer the origin of troubles 
resulting from its own vices to some other source, if possible. This 



432 TEXT-BOOK OF HYGIENE. 

thoorv of the American origin of syphilis is still held by some writers. 
Within a few years, Dr. Joseph Jones, of New Orleans, claims to 
have found evidences of syphilitic disease in the skulls and other 
bones from some of the prehistoric Indian mounds in Mississippi. 
These observations of Dr. Jones, have, however, not been verified 
by others. 

Although the first great epidemic of syphilis is clearly traceable 
to the period between the years 1493 and 1496, an examination of the 
older literature reveals many descriptions of disease which can only 
be explained by assuming them to refer to syphilis. The Old Testa- 
ment Scriptures contain numerous references to diseases of the genital 
organs. In most instances these troubles are ascribed to the wrath of 
God, although in some cases a pretty shrewd hint is given as to the 
causation of the affections. Finaly 22 remarks that the Hebrew word 
translated in all versions of the Bible by "flesh" signifies also the 
virile member. In this light, the references in Leviticus, XIII-XV; 
Numbers, XXV, 1-9, XXXI, 16-18; Deuteronomy, IV, 3; Joshua, 
XXII, 17; I Samuel, V, 6, 9, 12; Psalms CVI, 28-30; I Corinth- 
ians, X, 8; Ephesians, II, 11; and Colossians, II, 13, receive a new 
interpretation. Numerous innuendoes in the Latin classics, and more 
or less exact descriptions in the medical writings of Greece, Eome, 
China, and India, leave no room for doubt that venereal diseases, and 
probably among them syphilis, have existed from the earliest times. 

At the present day syphilis is the most widely prevalent of all 
contagious diseases. In 1873 Dr. F. E. Sturgis estimated that in 
New York 1 person out of every 18 suffered from it. This is con- 
sidered a moderate estimate. Dr. J. William White, of Philadelphia, 
pronounces the opinion that "not less than 50,000 people of all 
classes in that city are affected with syphilis." On this basis Gihon 
estimates the number of syphilitics in the United States at one time 
at 2,000,000. 23 

The disease is transmitted, in the vast majority of cases, during 
the performance of the sexual act, but there are numerous other ways 
in which it may be and frequently is communicated. In the special 
literature of the subject are records of many cases in which the dis- 
ease was acquired through a kiss, a bite, the act of suckling (from 
infant to nurse, and conversely), using a pipe, glass-blowers' mouth- 
piece, the finger of a midwife, the instrument of the dentist or sur- 



22 Arch. f. Dermat. u. Syphilis, II Jahrg. 1 Heft., p. 126. 

23 The Prevention of Venereal Diseases by Legislation, Sanitarian, 
June, 1882. 



GONORRHEA. 



433 



geon, inoculation of syphilitic secretion mixed with saliva in the 
process of tattooing, and many other ways. Numerous cases have 
been reported where physicians were inoculated on the ringer while 
examining a syphilitic patient. Recent observations seem to show 
that the disease is caused by a spirillum — Spirocheta pallida. 

The prophylactic measures which suggest themselves from a con- 
sideration of the nature of the disease are isolation of those infected, 
regular inspection of the class of persons through whom the disease 
is most frequently transmitted, i.e., prostitutes, and individual pre- 
cautions against acquiring it. Greater attention to cleanliness of the 
genital organs on the part of those indulging in promiscuous inter- 
course would aid largely in reducing the number of cases of syphilis. 

Recent investigations by Metchnikoff show that syphilitic infec- 
tion may be prevented by the local use of a salve containing calomel, 
33 grams; lanolin, 67 grams, and petrolatum, 10 grams. The appli- 
cation must be made within a few hours after coitus. Hypodermic 
injection of a solution of atoxyl (an arsenical preparation), in doses 
of 75 centigrams, followed by 60 centigrams, will prevent infection 
within two weeks. 




Fig. 47. — Micrococci Gonorrhea in Pus. (Park.) 



GONORRHEA. 

Gonorrhea is one of the venereal trio which is responsible for 
more misery, ill health, and "race suicide" than any other single 
sociologic factor. It has been estimated that fully 80 per cent, of cases 
of pelvic disease in women is caused by gonorrhea; 20 per cent, of 
blindness is due to gonorrheal infection of the new-born; 50 per 
cent, of all involuntary childless marriages are attributed to the 
same cause. Fitch asserts that of every one hundred women who 



434 TEXT-BOOK OF BYGIENE. 

have married men formerly infected with gonorrhea, hardly ten re- 
main well. The disease is caused by a diplococcus (Micrococcus gon- 
orrhea' or gonococcus) first observed by Neisser, in 1879. 

It is communicated through direct contact by sexual inter- 
course with individuals suffering from the disease, either in acute or 
chronic form. The chief source of infection is prostitution, and in 
considering prophylaxis we must deal with one of the most intricate 
social problems — the so-called "social evil/' It is generally conceded 
that education of the young of both sexes in the danger lurking in 
promiscuous intercourse and a general dissemination of knowledge 
concerning sexual functions and venereal diseases will go far to- 
ward remedying the evil. It is claimed that an injection of a few 
drops of a 20 per cent, solution of protargol post-coitum will prevent 
infection. Blindness can be prevented by attention to the eyes of 
the new-born, and instillation into the eyes of one drop of a solution 
of silver nitrate, 2 grains to the ounce. 

The third member of the venereal group — the soft chancre, or 
chancroid — is a localized ulceration caused by a bacillus discovered 
by Ducrey, in 1890. The affection is communicated through sexual 
intercourse, and seems to be propagated under conditions of extreme 
uncleanliness. 

DISEASES OF ANIMALS COMMUNICABLE TO MAN. 

Sheep-pock. — This is a highly contagious and infectious disease 
of sheep, resembling, in its symptoms, course, and fatality, small-pox 
as it occurs in the human race. It is believed by Bollinger to be dif- 
ferent from the form of small-pox produced in sheep, goats, horses, 
and other animals by the inoculation of human small-pox. Sheep- 
pock can be inoculated upon other animals and man, but only pro- 
duces a local disease at the point of inoculation in the latter. Sheep 
may be protected against this disease by inoculation with sheep-pock 
virus (ovination), or by vaccination with vaccine lymph. The pecu- 
liarity of sheep vaccinia is that it is a more or less generalized disease, 
the pustules being distributed over the body. Sheep-pock, when inoc- 
ulated upon human beings, does not produce a generalized infectious 
disease, but remains entirely local. 

Actinomycosis. — Veterinarians have frequently observed a dis- 
ease attacking the jaws of cattle and producing tumors, often with 
ulcerated surfaces. The bone is usually involved. The disease has 
heretofore been generally considered a sarcomatous growth. It is not 
seldom observed among the cattle in the western stockyards, where 



ANIMAL DISEASES COMMUNICABLE TO MAN. 435 

it is known in the vernacular as "swell-head." Recent investigations 
by Ponfick have shown that the growth consists of a vegetable para- 
site (actinomyces), and that it is inoculable upon other animals, and 
may be conveyed to man. A considerable number of cases have been 
observed in human beings in Germany, where the disease was first 
described by Ponfick, and several cases have been reported in this 
country. 

Bovine Tuberculosis (Perlsucht). — In cattle, tuberculosis occurs 
in two forms, miliary tubercles and cheesy masses in the lungs, and 
firm, pearly nodules on the serous membranes. These nodules do not 
break down, but may become calcified. 

Bovine tuberculosis is a frequent disease among cows kept in 




Fig. 48. — Actinomyces Hominis (Lung). X 350. 

damp, dark, and ill-ventilated stables. The disease, which is essen- 
tially the same as human tuberculosis, tubercle bacilli being present 
in the neoplasms, is believed to be transmissible to human beings 
by means of the milk or flesh of tuberculous animals. The sale of 
the meat of tuberculous cattle should be prohibited. 

Rabies. — Hydrophobia in the brute, and its communicability to 
man through a bite, has been known from the remotest antiquity. It 
occurs in dogs, foxes, wolves, horses, and other animals, and may 
be transmitted from any of them to human beings. 

The contagium of rabies, the infective poison, is contained prin- 
cipally in the saliva, and is usually inoculated by the teeth of the 
mad animal. 



436 TEXT-BOOK OF HYGIENE. 

Pasteur has shown that the greatest virulence of the rabies 
poison resides in the brain and spinal cord of the animal suffering 
from the disease. By attenuation of this virus, the nature of which 
has not yet been definitely determined, its virulence could be dimin- 
ished, and by inoculation of men and animals with the attenuated 
virus protection against the disease could be secured. The fact seems 
likewise established that the period of incubation of the inoculation- 
rabies is much shorter than that acquired in the usual way by bites of 
rabid animals. Hence, inoculation with the attenuated virus protects 
the bitten individual against the fatal outbreak of the unmodified 
disease. 




Fig. 49. — Colony of Anthrax Bacilli, slightly Magnified. 
(After Fliigge.) 

Anthrax. — Anthrax, or splenic fever (milzbrand), is an acute, 
highly contagious and infectious disease of herbiverous animals, 
which may be transmitted by inoculation or the ingestion of the virus 
to other animals and to man. 

The disease is due to a minute vegetable organism which is found 
in the blood and tissues of the diseased animals. This organism, 
Bacillus anthracis, was first discovered by Pollender, and has been 
thoroughly investigated by Davaine, Pasteur, Koch, and others. 

Inoculation of these bacilli or their spores always produces the 
disease in susceptible animals. Skins of animals not infrequently 
contain the virus, which may then gain access to the blood of persons 
engaged in handling them. Knackers, butchers, wool-sorters, and 



ANIMAL DISEASES COMMUNICABLE TO MAN. 437 

other persons liable to come in contact with sick animals, or hand- 
ling their flesh or hides, are subject to the infection, either by direct 
inoculation (through abrasions of the skin, etc.) or by inhalation of 
the spores of the bacillus. An intestinal form of anthrax in man, 
mycosis intestinalis, is sometimes produced by the consumption of 
meat of animals suffering, when killed, of splenic fever. Numerous 
instances have been reported. The diagnosis has been verified by dis- 
covering the bacillus of anthrax in the blood and various organs of 
the individuals attacked. 

In view of the dangerous character of the disease, persons coming 
in contact with animals suffering from anthrax should be warned of 
their peril. In order to protect other animals in a herd, strict isola- 




Fig. 50.— Bacillus Mallei. (Park.) 

tion of the infected, thorough disinfection of the stables occupied 
by them, and deep interment of the cadavers of those dead from the 
disease are indicated. The vaccination of animals with cultures of 
anthrax bacilli attenuated by being grown at 42° C. for twenty-four to 
forty-eight hours has been found to protect animals against infection. 

Glanders. — Glanders, or farcy, is a very fatal contagious disease 
of horses which may be communicated to other animals and to man. 
The cause of glanders has been discovered by Loffler to be a bacillus 
resembling the bacillus tuberculosis. Pure cultures of this bacillus, 
known as Bacillus mallei, were inoculated into animals, and followed 
by glanders in a number of the cases. 

The infection in man may occur either upon the seat of excoria- 
tions of the skin or mucous membranes, especially those of the nose, 



438 TEXT-BOOK OF HYGIENE. 

conjunctiva, and possibly by inhalation of infective particles float- 
ing in the air. 

Animals with glanders should be promptly killed and their cada- 
vers cremated or deeply buried. Xo part of the body of any animal 
dead with glanders should be allowed to be used. Infected stables 
should be thoroughly disinfected. 



RESUME OF SOME OF THE INFECTIOUS DISEASES. 

The following brief summary of the more important infectious 
diseases will be found useful: — 

Abscesses. — Localized suppuration, caused principally by the so- 
called pyogenic cocci (staphylococci, streptococci, etc.), but may be 
caused by other bacteria (B. coli, B. typhosus). So-called "cold ab- 
scesses" are caused by the tubercle bacillus. The affection may be 
prevented by thorough sterilization of instruments and dressings 
which come in contact with a wound, as well as by rendering such 
wound free from germs. Laboratory diagnosis: Demonstration of 
germ in the pus. 

Actinomycosis. — Caused by a fungus, actinomyces bovis or ray 
fungus. It is a disease of animals communicated to man by way of 
the alimentary or respiratory tract or wounds. Prophylaxis includes 
the destruction of the abscesses. Laboratory diagnosis: Demonstra- 
tion of characteristic fungus in the discharges. 

Anthrax. — Caused by Bacillus anthracis. It is a disease of ani- 
mals communicated to man, and may be transmitted by direct contact 
or by insects, the consumption of flesh from the diseased animal 
(intestinal anthrax), or inhaling the dust from the hair of the in- 
fected animals (pulmonary anthrax, or wool-sorters' disease). The 
prophylaxis includes isolation of the diseased animals, the complete 
destruction of the carcasses, and vaccination of the exposed stock. 
Laboratory diagnosis: Demonstration of characteristic bacillus in the 
blood or point of infection. 

Cholera. — Caused by Spirillum cholera?. Transmitted by water 
and food, principally the former. The period of quarantine, one 
week. Prophylaxis consists in sterilizing the food and drink, and 
disinfection of the stools. Laboratory diagnosis: Cultivation of the 
spirillum from the feces. 

Diphtheria. — Caused by Bacillus diphtheria? of Klebs-Loffler. 
Transmitted by direct contact, fomites, and air. Period of quarantine, 
until two successive cultures from the throat are negative. Prophyl- 



RESUME OF SOME INFECTIOUS DISEASES. 439 

axis consists in isolation, disinfection of upper respiratory passages 
by mild antiseptics, immunization with antitoxin, disinfection of 
premises. Laboratory diagnosis: Cultivation of the Klebs-Loffler 
bacillus on blood serum, from the throat of suspected patients. 

Dysentery. — The bacillary form is caused by Bacillus shigce, the 
amebic form by Ameba dysenteric. Transmitted by water and food. 
Prophylaxis consists in disinfection of the stools and sterilization of 
food and drink. Laboratory diagnosis: The cultivation of the bacil- 
lus from the feces or the microscopic demonstration of the ameba. 

Glanders. — Caused by Bacillus mallei. Transmitted by inhala- 
tion of, or infection of wounds with nasal secretions and discharges 
from infected animals. Prophylaxis consists in disinfection of se- 
cretion and destruction of carcasses. laboratory diagnosis: Injection 
of culture from secretion into guinea-pigs ; development of swelling of 
testicle is characteristic; to detect latent glanders, use mallein. 

Gonorrhea. — Caused by Micrococcus gonorrheal (gonococcus). 
Transmitted by sexual contact, rarely fomites. Prophylaxis consists 
in strict avoidance of promiscuous intercourse and local disinfection 
after such intercourse. Laboratory diagnosis: Demonstration of the 
gonococci in the discharge, or cultivation on serum-agar. 

Hydrophobia. — Caused by unknown micro-organism. Trans- 
mitted by bites of rabid animals. Prophylaxis consists in the destruc- 
tion of animals suffering from rabies and isolation of those bitten; 
cauterization of wound and Pasteur treatment. Laboratory diagnosis: 
Reproduction of the disease by subdural inoculation into the lower 
animals ; demonstration of certain histological changes in the ganglia 
of suspected animals. 

Influenza. — Caused by Bacillus influenza of Canon and Pfeiffer. 
Transmitted by fomites and inhalation. Prophylaxis consists in iso- 
lation and disinfection of discharges. Laboratory diagnosis: Demon- 
stration of bacillus in the secretions from respiratory passages. 

Leprosy. — Caused by the Bacillus leprce. Believed to be trans- 
mitted by insects. Prophylaxis consists in isolation and destruction 
of insects and vermin. Laboratory diagnosis: Demonstration of the 
bacillus in the affected tissues. 

Malaria. — Caused by the Plasmodium malaria?. Transmitted by 
mosquitoes (anopheles). Prophylaxis consists in destruction of mos- 
quitoes and prophylactic use of quinine. Laboratory diagnosis: 
Demonstration of the parasite in the blood, either fresh or stained, 
of the patient. 

Measles. — Supposed to be caused by a bacillus discovered by 



4-10 TEXT-BOOK OF HYGIENE. 

Canon and Pielicke. Transmitted by direct contact and fomites. 
Period of quarantine, sixteen days. Prophylaxis consists in isola- 
tion, disinfection of fomites, skin, and secretions from nose and 
mouth, and final fumigation of sick-room. 

Mumps. — Cause unknown. Transmitted by direct contact. 
Period of quarantine, twenty-four days. Prophylaxis consists in iso- 
lation and disinfection of secretions from upper respiratory passages. 

Plague. — Caused by Bacillus pestis. Transmitted by rats, fleas, 
and inhalation of patient's sputum. Period of quarantine, ten days. 
Prophylaxis consists in isolation, destruction of rats and vermin, and 
disinfection of all discharges. Laboratory diagnosis: Demonstration 
of the bacillus in the pus from the buboes ;. animal inoculation. 

Pneumonia. — Caused by Diplococcus lanceolatus (pneumococcus). 
Transmitted by fomites. Proprrylaxis consists in isolation and disin- 
fection of sputum. Laboratory diagnosis: Demonstration of the 
pneumococci in the sputum. 

Kelapsing Fever. — Caused by Spirillum dbermeieri. Mode of 
transmission obscure; possibly insects. Prophylaxis consists in the 
protection from bites of insects. Laboratory diagnosis: Demonstra- 
tion of the spirillum in the blood. 

Scarlet Fever. — Cause unknown. Transmitted by direct contact, 
fomites, milk. Period of quarantine, ten days after exposure; period 
of isolation of patient, about six weeks. Prophylaxis consists in isola- 
tion, disinfection of skin and fomites, and final fumigation of sick- 
room. 

Small-pox. — Cause unknown. Transmitted by direct contact and 
fomites. Period of quarantine, 16 days after exposure; period of 
isolation of patient, until disappearance of eruption. Prophylaxis 
consists in isolation, vaccination, disinfection of skin and fomites, 
and final fumigation. 

Syphilis. — Supposed to be caused by Spiroclieta pallida. Trans- 
mitted by direct contact (coitus, kissing) and fomites. Prophylaxis 
consists in disinfecting the mouth of patient and exclusive use of 
eating and drinking utensils. The patient should be enjoined from 
kissing and such contact with the well as would be liable to lead to 
infection. Physicians and dentists should be particularly careful not 
to infect themselves, and more especially not to become carriers of 
infection. Laboratory diagnosis: Demonstration of the spirochete in 
the lesions. 

Tetanus. — Caused by Bacillus tetani. Transmitted by infecting 
deep wounds with earth containing the micro-organism. Prophylaxis 



RESUME OF SOME INFECTIOUS DISEASES. 441 

consists in free incision, cauterization, and injection of antitetanic 
serum. Laboratory diagnosis: Demonstration of the bacillus on the 
objects which caused the injury, by the aid of animal inoculations. 

Typhoid Fever. — Caused by the Bacillus typhosus. Transmitted 
through water, milk, food, and fomites, also by contact with infected 
feces. Prophylaxis consists in disinfection of stools and urine of 
patient as well as fomites; purification of polluted water-supply; 
sterilization of suspected food and drink; protection against flies. 
Laboratory diagnosis: Demonstration of the typhoid bacillus in the 
blood ; Widal test ; test of urine for diazo-reaction. 

Typhus. — Cause unknown. Transmitted by direct contact, fo- 
mites, and air. Period of quarantine, fourteen days; period of isola- 
tion, about four weeks. Prophylaxis consists in isolation and final 
fumigation. 

Tuberculosis. — Caused by Bacillus tuberculosis. Transmitted by 
inhalation of dried sputum, consumption of infected food. Prophy- 
laxis consists in disinfection of sputum and protection of food-supply. 
Final fumigation of premises. Laboratory diagnosis: Demonstration 
of the tubercle bacillus in the sputum or other discharges ; the tuber- 
culin test. 

Whooping Cough. — Cause unknown. Transmitted by direct con- 
tact and by inhalation of ejected secretions. Prophylaxis consists in 
isolation, disinfection of sputum, and final fumigation of premises. 

Yellow Fever. — Cause unknown. Transmitted by bite of mos- 
quito (stegomyia fasciata). Period of quarantine, fourteen days after 
exposure. Prophylaxis consists in protection against mosquitoes. 



QUESTIONS TO CHAPTER XVII. 

HISTORY OF EPIDEMIC DISEASES. 

Of what advantage is the study of the history of epidemic diseases? 
What are some of the most important maladies of this class? To what are 
they all due? 

What are some of the synonyms of the Oriental plague? What are 
some of its characteristic symptoms? What is the date of the first clear 
account of it? How long did this epidemic persist? When did it make its 
second incursion into Europe? What was one of the peculiar symptoms of 
this epidemic? What was its estimated mortality? What were some of its 
moral effects? When was its final incursion into Western Europe? What 
minor epidemics of it have there been since? When was the last, and where? 
Is it now endemic anywhere? To what was its origin formerly ascribed? 
What conditions are always present when the plague prevails? What is 
another evident factor in its causation? How is it generally transmitted? Is 
it a germ disease? What are the measures of prevention therefore indicated? 

What is the sweating sickness? What are some of its characteristic 
symptoms and peculiarities ? What is evidently its nature ? Is "there any 
class exempt from it? What favors its spread? What relation has it to 
cholera? When did it first appear in England? When for the last time? 
Where has it appeared since? Have there been many outbreaks in Europe? 

What are the earliest details regarding small-pox? When was it sup- 
posed to have been introduced into Europe? Who made the first distinct 
reference to it in medical literature? When? What was the estimated mor- 
tality from this disease in Europe previous to the introduction of vaccination? 
Where has it been very fatal in its devastations in recent years? What other 
countries and peoples have suffered from it? What is the mortality from 
unmodified small-pox? How is the disease transmitted? What factors are 
necessary to cause an outbreak? What may carry the poison? For what 
distance about a patient may the air be infectious? In what stages of the 
disease is it contagious? What races are more commonly attacked, and among 
which is it more fatal? 

Does one attack of small-pox always confer future immunity from the 
disease? Wherein is the popular belief, that persons suffering from an acute 
or chronic disease are less liable to incur small-pox than the healthy, at 
fault? Which maladies are most likely to afford this immunity? When does 
such immunity appear to cease? 

When do epidemics of small-pox usually begin? In what seasons do they 
spread most rapidly? Does the disease spread rapidly at first? Has the 
specific organism of small-pox been certainly discovered? 

When was the first attempt to limit the fatality of small-pox by inocu- 
lation made in Europe? When was the practice introduced into England, and 

(442) 



QUESTIONS TO CHAPTER XVII. 443 

by whom? What were the details of the method as then practiced? What 
were the characteristics of the disease thus produced? Was the practice 
altogether without danger to the one inoculated? What other grave objec- 
tion was there to such inoculations? When was the practice of inoculation 
introduced into America, and by whom? How long was it continued in 
England and in America? Where was it practiced before its introduction 
into Europe ? 

What led to the discovery of vaccination? Who first practiced it? 
When? To whom is due the merit of demonstrating and publishing the value 
of vaccination? When did he perform his first vaccination, and with what 
results? When did he publish the first pamphlet in relation to it? When 
was vaccination introduced into America, and by whom? 

What is the relation of vaccinia (cow-pox) to small-pox? What are 
the symptoms produced in the case of a successful vaccination? When may 
the individual be considered to be thoroughly protected? Is the immunity 
absolute for life? What is the character of an attack of small-pox in an 
individual who has once been vaccinated? Does repeated vaccination increase 
the immunity? What effect has vaccination had on the mortality from small- 
pox? On the prevalence of the disease? 

What important precaution should be observed in all vaccinations? 
Why? When should children be vaccinated? When should they be revac- 
cinated? What are some of the peculiarities following upon revaccination ? 
What are some of the objections urged against humanized virus? Are these 
all valid? What are some of its advantages? How is it to be inoculated? 
Hoav is animal virus obtained? How is it to be used? In what way do the 
results from using it differ from those of humanized virus? 

What complications are likely to occur in the course of the vaccinia? 
What are some of the causes of these complications? What subjects are 
unfavorable ones for vaccination? When may vaccination be properly de- 
layed? What diseases may be communicated by or may follow vaccination? 
What cases should be promptly revaccinated ? 

What besides vaccination is highly important in the prophylaxis of 
small-pox? What precautions should be observed in the care of one sick 
with small-pox? What are the best disinfectants for such cases? When 
is all danger of infection over? 

Where is Asiatic cholera endemic? What can be said of its ravages 
there? When were the first authentic accounts of it given? When did the 
disease first become epidemic outside of India? What were some of the 
countries visited? When did it first appear in England? When and where 
in America? When did this outbreak from India end? When did it again 
become pandemic, and how long before it again reached the United States? 
What were the ports through which it entered? How long did it persist in 
this country? How long in South America? When was the next visitation 
to this country? What parts of South America were first invaded at this 
time? Where else was cholera raging during these periods, and where was 
it practically endemic? 



444 TEXT-BOOK OF HYGIENE. 

When was the last serious importation of the disease into this country, 
and by what port did it enter? Where else, and when, have there been im- 
portant epidemics since this date? What does the history of all these epi- 
demics demonstrate? What factors must concur that there may be an 
epidemic? What is the specific cause of cholera? Who discovered it? When? 
Is the disease contagious? How is it spread? What conditions seem to be 
necessary for its propagation? When do outbreaks usually occur, and when 
do they subside? Why is the disease endemic in India? How do these con- 
ditions predispose the victims to the disease? Are these conditions peculiar 
to India? Where else may they exist? 

How is the specific organism given off from the human body? How 
does it usually gain entrance into others? What evidence is there of this 
(see chapter on Water) ? What other agencies may aid in disseminating 
the disease? 

What are the measures of prophylaxis against cholera? How can the 
entrance of the disease into a community be prevented? What measures of 
local sanitation may be even more effective? Why? How shall the drinking- 
water and food be rendered harmless? 

How may one guard against an individual predisposition to cholera? 
What measure of personal prophylaxis is useful? What is the rationale of 
this ? What disease may simulate cholera during an epidemic, and to what 
is it often due? 

In times of cholera epidemics, what sanitary measures are to be estab- 
lished? What disinfectants are to be used? What articles are to be disin- 
fected, and how? What are some of the objections to the indiscriminate use 
of the bichloride of mercury? What may be used in its stead? What does 
Koch recommend, and what objection is there to its use? What plan should 
be pursued at the beginning of an epidemic? 

When was relapsing fever first described? When was it first observed 
in America? When did it last appear here? What predisposing conditions 
favor it? What is its specific exciting cause? Where is the germ found? 
What are the preventive measures to be used against relapsing fever? 

How long has typhoid fever been known as a distinct disease? Where 
is typhoid fever common? When is it most prevalent? What persons and 
ages are most subject to it? To what is the disease due? Where is it found? 
Is the disease contagious? Where is the poison developed? Does it arise 
de novo? How may the poison be conveyed to human beings? What prophyl- 
axis may be employed against typhoid fever? What are the requisites for 
prevention ? 

When were the earliest authentic accounts of typhus fever made? What 
predisposing conditions favor its development and spread? When is it more 
prevalent? By what is it limited? Where is it apt to occur? What class 
of persons is most likely to be attacked? Is it contagious? How may it be 
prevented? What measures are to be pursued during an outbreak of the 
disease? 



QUESTIONS TO CHAPTER XVII. 445 

Where is the present home of yellow fever? What localities are most 
liable to epidemics of this disease? What is the date of the first authentic 
account of it? When and where did it first appear in the United States? 
Has it ever originated here or been endemic? How many time3 has it been 
epidemic in this country in the last two centuries? When and where was 
the last epidemic? In what season do epidemics occur? In what climates may 
it be endemic? What climatic conditions seem to be necessary for an out- 
break? What is probably its specific cause? Has this been discovered? What 
is one of the principal factors in its spread? Is the disease contagious? 
How is the poison conveyed? What is necessary to the propagation of the 
disease? What preventive measures are to be employed against yellow fever? 

What is to be done, should the disease become epidemic in a city? Will 
this be efficacious in most cases? 

Who first distinguished between scarlet fever and measles? Which dis- 
ease is more prevalent? What countries have been practically exempt from 
scarlet fever? When was scarlet fever first observed in America? When do 
epidemics of measles usually begin? When of scarlet fever? What is the 
exciting cause of each disease, and how may it be conveyed? Have bad hy- 
gienic surroundings an influence in the propagation of either disease ? What 
are measures for prevention in both cases? 

How old is the history of diphtheria? When was it first observed in 
this country? When did it again prevail epidemically here? How are vari- 
ous epidemics marked? Is it contagious? How may it be conveyed? What 
is the exciting cause? Is diphtheria identical with croup? What plan should 
be pursued for prevention regarding the two diseases? Is diphtheria trans- 
missible to animals? What precautions should be taken with a person sick 
with diphtheria? How long should children who have had diphtheria, scarlet 
fever, small-pox, or measles be detained from school? Why? 

What is dengue? When and by whom was it first observed in the 
United States? When does an epidemic begin, and when does it stop? To 
what countries is the disease limited? Is it contagious? How is it propa- 
gated? Who are susceptible? What are the measures of prevention that may 
be employed? Is the disease fatal? 

What is the date of the earliest accounts of epidemic influenza? What 
are some of its synonyms? When did it first prevail in America? When was 
the last epidemic? How was this one complicated? Are animals subject to 
this disease? Is it contagious? How is it transmitted? When is it most 
prevalent? What are the measures of prophylaxis against it? 

When was epidemic cerebro-spinal meningitis first recognized? When 
did it appear in America? When was the first epidemic here? When the 
next? When the last? Is it contagious or infectious? What is its tendency? 
When is it most liable to occur? What influence has climate upon it? What 
factors seem to favor an outbreak? What ages are most subject to it? What 
is the prophylactic treatment? 

When and where does syphilis seem to have had its origin? Are there 
any traces of evidence of its existence before this? What can be said of its 



44G TEXT-BOOK OF HYGIENE. 

comparative prevalence? How is it usually transmitted? In what other 
ways may it be conveyed? What prophylactic measures are indicated? 

What are some of the serious diseases of animals communicable to man? 
What is sheep-pock, and what is its peculiarity when inoculated upon human 
beings ? 

What is actinomycosis? What are some of the synonyms? To what is 
it due? 

In what two forms does tuberculosis occur in cattle? Is it common 
among them? How is it related to human tuberculosis? How may it be 
transmitted to man? What precautions should be enforced to prevent this 
transmission? 

What is rabies? How is it transmitted? Where is the contagium con- 
tained? Where does the poison of greatest virulence reside? How may the 
virus be cultivated, and what changes take place in it? How may immunity 
against the disease be produced? Who discovered and advocated this method 
of inoculation? 

What is anthrax? What are some of its synonyms? To what is it 
due? How may it be transmitted? W T hat are the measures of prophylaxis 
against it, both for man and animals? 

What is glanders ? To what is it due ? How may infection occur ? What 
should be done with animals sick with this disease? What else should be 
done? 



CHAPTER XVIII. 

ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 

Much confusion exists in the popular mind, and even among 
physicians, as to the exact meaning of the terms at the head of this 
chapter. By many they are used synonymously, and hence frequently 
give rise to ambiguity and misunderstanding. 

Antisepsis, which is so frequently confounded with disinfection, 
should be more accurately denned than is usual by writers. An anti- 
septic is an agent which retards, prevents, or arrests putrefaction, 
decay, or fermentation. It does not necessarily destroy the vitality of 
the organisms upon which these processes depend. An antiseptic may 
also arrest the development of the organisms which cause infectious 
diseases, and may hence be used as a preventive of such diseases. But 
antiseptics do not destroy the life of disease-germs, and hence cannot 
be relied upon when such organisms are present. 

By disinfection, in the proper and restricted use of the term, is 
meant the destruction of the specific infectious material which causes 
infectious diseases. If the view is accepted that all infectious diseases 
are due to micro-organisms or germs, then a disinfectant is equivalent 
to a germicide. In sanitary practice and experimental investigations 
this view is, in fact, adopted. In testing the action of various disin- 
fecting agents upon infectious material, the biological test is the one 
universally relied upon by experimenters, and no observations upon 
disinfection based upon chemical tests alone would be accepted by 
sanitarians as conclusive. It may therefore be assumed for practical 
purposes that no agent can be accepted as a disinfectant if it is not 
also a germicide. From this it follows that disinfection, to be trust- 
worthy, must be thorough. "There can be no partial disinfection of 
infectious material; either its infectious power is destroyed or it is 
not. In the latter case there is a failure to disinfect/' 1 Obviously, 
also, there can be no disinfection in the absence of infectious material. 
Fecal discharges, a diseased body or corpse, clothing, bedding, an 
apartment, a ship, or a hospital ward may or may not be infected. In 
the former case we may speak of disinfecting them; in the latter it 
would be an inappropriate use of the word. 



x Report of Committee on Disinfectants of the American Public Health 
Association, p. 236. 

(447) 



448 



TEXT-BOOK OF HYGIENE. 



Confusion is also liable to arise by considering disinfectants and 
deodorizers as synonymous. Deodorants merely remove the offensive 
odors, and may not possess any disinfecting power whatever. Thus, 
one of the most efficient disinfectants at cur command (mercuric 
chloride) is not a deodorizer at all, except by preventing putrefaction. 
On the other hand, some of the most effective deodorants have only a 
subordinate position in the scale of disinfectants. 

Careful investigations have shown that there is a wide divergence 
between various disinfecting agents in their influence upon disease- 
germs, some being efficient in high dilutions, while others require to 
be brought in contact with the germs in great concentration. For 
example, mercuric chloride will act as an efficient poison to certain 
disease-germs (anthrax spores) in the proportion of 1 to 1000, while 
zinc chloride must be used in the proportion of 1 to 5 (or 20 per cent.) . 

It has been further discovered that different disease-germs pre- 
sent varying resisting power to the same disinfecting agent, some 
being easily destroyed, while others are much more resistant. For 
example, the following table shows a number of experiments made 
by Dr. Meade Bolton for the American Committee on Disinfectants : — 



T 


A.BLE LVII. 






Organism. 


Chloride of 
Lime. 


Mercuric 
Chloride. 


Carbolic Acid. 


Typhoid bacillus 

Cholera spirillum .... 
Anthrax spores 

Staphylococcus aureus . . . 
Staphylococcus citreus . . 
Staphylococcus albus . . . 


1 : 2000 
1 : 2000 
1:100 

1:200 

1:50 

1:200 


1:10,000 
1:10,000 
1:1000 


1:100 
1:100 
1:50 

(Uncertain.) 

1:100 
1:100 
1:100 



Assuming that infectious diseases are caused by micro-organisms, 
and that these are different from the micro-organisms of ordinary 
decay or putrefaction, it can be readily understood that the processes 
of organic decomposition may themselves act as disinfectants. It is 
known, for example, that when a fermenting liquid putrefies, the 
organisms of fermentation disappear and give place to the organisms 
of putrefaction (bacterium termo, etc.). So, likewise, the bacilli of 
anthrax and of tuberculosis are killed by the putrefactive process, if 
this takes place in the absence of free oxygen. Furthermore, the 
reproduction of organisms of a certain kind ceases when certain 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 449 

chemical changes take place in their environment. Fermentation 
in a saccharine liquid ceases and the ferment-organisms die when the 
accumulation of the product of the fermentation (alcohol) has 
reached a certain proportion, although there may still be undecom- 
posed sugar present. In like manner it is intelligible that the pro- 
ducts of micro-organisms may eventually destroy their producers, and 
so place a limit to the morbid process. The specific cause of small- 
pox, yellow fever, cholera, and similar infectious diseases is rapidly 
destroyed when decomposition of the corpses of those dead with such 
diseases sets in. Hence, the reason why infectious diseases are not 
spread from cemeteries. 

From the foregoing it may be gathered that disinfection consists 
chiefly in a struggle against organized disease-germs. 2 As, how- 
ever, experiments and observations have shown that the life-history 
of disease-germs varies with the different organisms involved, it be- 
comes evident that specific directions concerning disinfection can be 
given only when the life-history of the specific organism is known. 

The American Committee on Disinfectants, to whose work refer- 
ence has already been made, divides disinfectants into two classes: 
those efficient for the destruction of infectious material containing 
spores, and those which will destroy infectious material only in the 
absence of spores. The recommendations of the committee, covering 
not only the appropriate disinfectant to be used for the destruction 
of the organisms, but also the conditions under which the agent 
should be used, are as follow: — 

The most useful agents for the destruction of spore-containing infectious 
material are: — 

1. Fire. Complete destruction by burning. 

2. Steam under pressure. 105° C. (221° F.) for ten minutes. 

3. Boiling in water for half an hour. 

4. Chlorinated lime. 3 A 4-per-cent. solution. 

5. Mercuric chloride. A solution of 1 to 500. 

For the destruction of infectious material which owes its infecting power 
to the presence of micro-organisms not containing spores, the committee rec- 
ommends: — 

1. Fire. Complete destruction by burning. 

2. Boiling in water for ten minutes. 

3. Dry heat. 110° C. (230° F.) for two hours. 

4. Chlorinated lime. 3 A 2-per-cent. solution. 



2 Mueller und Falk, in Realencyclopcedie d. ges. Heilk., Bd. IV., p. 62. 

3 Should contain at least 25 per cent, of available chlorine. 



450 TEXT-BOOK OF HYGIENE. 

.">. Solution of chlorinated soda.* A 10-per-cent. solution. 
ti. Mercuric chloride. A solution of 1 to 2000. 

7. Sulphur dioxide. Exposure for twelve hours to an atmosphere con- 
taining at Least 4 volumes per cent, of this gas in presence of moisture. 6 

8. Cat bolic acid. A 5-per-cent. solution. 

9. Sulphate of copper. A 5-per-cent. solution. 
10. Chloride of zinc. A 10-per-cent. solution. 

The committee would make the following recommendations with refer- 
ence to the practical application of these agents for disinfecting purposes: — 

For Excreta. 

(a) In the sick-room: — 

1. Chlorinated lime in solution, 4 per cent. 
In the absence of spores: — 

2. Carbolic acid in solution, 5 per cent. 

3. Sulphate of copper in solution, 5 per cent. 

(b) In privy-vaults: — 

1. Mercuric chloride in solution, 1 to 500. 6 

2. Carbolic acid in solution, 5 per cent. 

(c) For the disinfection and deodorization of the surface of masses of 
organic material in privy-vaults, etc.: — 

Chlorinated lime in powder. 

For Clothing, Bedding, etc. 

(a) Soiled underclothing, bed-linen, etc. : — 

1. Destruction by fire, if of little value. 

2. Boiling for at least half an hour. 

3. Immersion in a solution of mercuric chloride of the strength 

of 1 to 2000 for four hours. 

4. Immersion in a 2-per-cent. solution of carbolic acid for four 

hours. 

(b) Outer garments of wool or silk, and similar articles, which would 
be injured by immersion in boiling water or in a disinfecting solution: — 

1. Exposure in a suitable apparatus to a current of steam for 

ten minutes. 

2. Exposure to dry heat at a temperature of 110° C. (230° F.) 

for two hours. 



4 Should contain at least 3 per cent, of available chlorine. 

5 This will require the combustion of between \ x k to 2 kilogrammes of 
sulphur for every 28 cubic metres of air-space. The vaporization of liquid 
sulphur-dioxide can be more accurately regulated. 

6 The addition of an equal quantity of potassium permanganate as a de- 
odorant, and to give color to the solution, is to be recommended. 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 451 

(c) Mattresses and blankets soiled by the discharges of the sick: — 

1. Destruction by fire. 

2. Exposure to superheated steam (105° C. =221° F.) for ten 

minutes. (Mattresses to have the cover removed or freely 
opened. ) 

3. Immersion in boiling water for half an hour. 

Furniture and Articles of Wood, Leather, and Porcelain. 

Washing, several times repeated, with solution of carbolic acid, 2 per 
cent. 

For the Person. 

The hands and general surface of the body of attendants of the sick, 
and of the convalescents, should be washed with — 

1. Solution of chlorinated soda diluted with nine parts of water 

(1 to 10). 

2. Carbolic acid, 2-per-cent. solution. 

3. Mercuric chloride, 1 to 1000. 

For the Dead. 

Envelop the body in a sheet thoroughly saturated with — 

1. Chlorinated lime in solution, 4 per cent. 

2. Mercuric chloride in solution, 1 to 500. 

3. Carbolic acid in solution, 5 per cent. 

For the Sick=room and Hospital Wards. 

(a) While occupied, wash all surfaces with — 

1. Mercuric chloride in solution, 1 to 1000. 

2. Carbolic acid in solution, 2 per cent. 

(b) When vacated: — 

Fumigate with sulphur dioxide for twelve hours, burning at least 1^ 
kilogrammes sulphur for every 28 cubic metres of air-space in the room; 
then wash all surfaces with one of the above-mentioned disinfecting solutions, 
and afterward with soap and hot water; finally throw open doors and win- 
dows and ventilate freely. 

For Merchandise and the Mails. 

The disinfection of merchandise and of the mails will only be required 
under exceptional circumstances; free aeration will usually be sufficient. 
If disinfection seems necessary, fumigation with sulphur dioxide will be the 
only practicable method of accomplishing it without injury. 

Rags. 

fa) Rags which have been used for wiping away infectious discharges 
should at once be burned. 



452 TEXT-BOOK OF HYGIENE. 

(b) Rags collected for the paper-makers during the prevalence of an 
epidemic should be disinfected, before they are compressed in bales, by — 

1. Exposure to superheated steam (105° C. = 221° F.) for ten 

minutes. 

2. Immersion in boiling water for half an hour. 

Ships. 

fa) Infected ships at sea should be washed in every accessible place, and 
especially localities occupied by the sick, with — 

1. Solution of mercuric chloride, 1 to 1000. 

2. Solution of carbolic acid, 2 per cent. 

The bilge should be disinfected by the liberal use of a strong 
solution of mercuric chloride. 

(b) Upon arrival at a quarantine station, an infected ship should at 
once be fumigated with sulphurous-acid gas, using 1% kilogrammes of sul- 
phur for every 28 cubic metres of air-space; the cargo should then be dis- 
charged on lighters; a liberal supply of the concentrated solution of mercuric 
chloride (1 to 32 ) should be thrown into the bilge, and at the end of twenty- 
four hours the bilge-water should be pumped out and replaced with pure sea- 
water; this should be repeated. A second fumigation after the removal of 
the cargo is recommended. All accessible surfaces should be washed with one 
of the disinfecting solutions heretofore recommended, and subsequently with 
soap and hot water. 

For Railway=cars. 

The directions given for the disinfection of dwellings, hospital wards, 
and ships apply as well to infected railway-cars. The treatment of excreta 
with a disinfectant before they are scattered along the tracks seems desirable 
at all times, in view of the fact that they may contain infectious germs. 
During the prevalence of an epidemic of cholera this is imperative. For this 
purpose the standard solution of chlorinated lime is recommended. 

From the foregoing it would appear that heat, chlorinated lime, 
mercuric chloride, solution of chlorinated soda (Labarraque's solu- 
tion), carbolic acid, sulphate of copper, zinc chloride, and sulphur 
dioxide (sulphur fumes) are the most generally available disinfec- 
tants. 

The following "general directions" for the practical application 
of disinfection are given by the committee : — 

Disinfection of Excreta, etc. — The infectious character of the dejections 
of patients suffering from cholera and typhoid fever is well established; and 
this is true of mild eases and of the earliest stages of these diseases, as well 
as of severe and fatal cases. In cholera, diphtheria, yellow fever, and scarlet 
fever all vomited material should also be looked upon as infectious. And in 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 453 

tuberculosis, diphtheria, scarlet fever, and infectious pneumonia the sputa of 
the sick should be disinfected or destroyed by fire. It seems advisable, also, to 
treat the urine of patients sick with an infectious disease with one of the dis- 
infecting solutions below recommended. 

Chloride of lime, or bleaching powder, is perhaps entitled to the first 
place for disinfecting excreta, on account of the rapidity of its action. The 
following standard solution is recommended: — 

Dissolve chloride of lime (chlorinated lime, bleaching powder) of the 
best quality' 7 in pure water in the proportion of 6 ounces to the gallon (45 
grammes to the litre). 

Use 1 quart (1 litre) of this solution for the disinfection of each dis- 
charge in cholera, typhoid fever, etc. 8 Mix well, and leave in the vessel for 
at least one hour before throwing into privy-well or water-closet. The same 
directions apply for the disinfection of vomited matters. Infected sputum 
should be discharged directly into a cup half full of the solution. 9 A 5-per 
cent, solution of carbolic acid may be used instead of the chloride-of-lime 
solution, the time of exposure to the action of the disinfectant being four 
hours. 

Disinfection of the Person. — The surface of the body of a sick person 
or of his attendants, when soiled with infectious discharges, should be at 
once cleansed with a suitable disinfecting agent. For this purpose, solution 
of chlorinated soda (liquor sodse chlorinatse — Labarraque's solution) diluted 
with 9 parts of water, or the standard solution of chloride of lime diluted 
with 3 parts of water, may be used. A 2-per-cent. solution of carbolic acid 
is also suitable for this purpose, and under proper medical supervision the 
use of a solution of corrosive sublimate (1 to 1000) is to be recommended. 

In diseases like small-pox and scarlet fever, in which the infectious agent 
is given off from the entire surface of the body, occasional ablutions with the 
above-mentioned solution of chlorinated soda are recommended. 

In all infectious diseases the body of the dead should be enveloped in 
a sheet saturated with the standard solution of chlorinated lime, or with a 
5-per-cent. solution of carbolic acid, or a 1 to 500 solution of corrosive sub- 
limate. 

Disinfection of Clothing. — Boiling for half an hour will destroy the 
vitality of all known disease-germs, and there is no better way of disinfecting 
clothing or bedding which can be washed than to put it through the ordinary 
operations of the laundry. No delay should occur, however, between the time 
of removing soiled clothing from the person or bed of the sick and its im- 
mersion in boiling water, or in one of the following solutions until this can 
be done: — 



7 Good chloride of lime should contain at least 25 per cent, of available 
chlorine. Recently nascent chlorine for disinfecting purposes has been ob- 
tained on a large scale by the electrolysis of sea-water. 

8 For a very copious discharge use a larger quantity. 

9 Recently a small spitting-cup made of stiff paper has been introduced 
especially for the use of consumptives. The cup is carried about by the 
patient or kept within reach. When the cup has been in use for a time, and 
before the sputa can become desiccated, it is thrown into the fire and burned. 



454 TEXT-BOOK OF HYGIENE. 

Corrosive sublimate, 1 gramme to the litre (1 to 1000), or carbolic acid 
(pure), 8 grammes to the litre. 

The articles to be disinfected must be thoroughly soaked with the dis- 
infecting solution and left in it for at least two hours, after which they may 
be wrung out and sent to the wash. 10 

Clothing or bedding which cannot be washed should be disinfected by 
steam in a properly-constructed disinfection chamber. In the absence of a 
suitable steam disinfecting apparatus, infected clothing and bedding should 
be burned. 

Disinfection of the Sick-room. — In the sick-room no disinfectant can 
take the place of free ventilation and cleanliness. It is an axiom in sanitary 
science that it is impracticable to disinfect an occupied apartment for the 
reason that disease-germs are not destroyed by the presence in the atmosphere 
of any known disinfectant in respirable quantity. Bad odors may be neu- 
tralized, but this does not constitute disinfection in the sense in which the 
term is here used. These bad odors are, for the most part, an indication of 
want of cleanliness or of proper ventilation, and it is better to turn con- 
taminated air out of the window or up the chimney than to attempt to purify 
it by the use of volatile chemical agents, such as carbolic acid, chlorine, etc., 
which are all more or less offensive to the sick, and are useless so far as 
disinfection — properly so called — is concerned. 

When an apartment which has been occupied by a person sick with an 
infectious disease has been vacated, it should be disinfected. The object of 
disinfection in the sick-room is mainly the destruction of infectious material 
attached to surfaces or deposited as dust upon window-ledges, in crevices, etc. 
If the room has been properly cleansed and ventilated while still occupied by 
the sick person, and especially if it was stripped of carpets and unnecessary 
furniture at the outset of his attack, the difficulties of disinfection will be 
greatly reduced. 

All surfaces should be thoroughly washed with the standard solution 
of chloride of lime, diluted with 3 parts of water, or with 1 to 1000 solution 
of corrosive sublimate. The walls and ceiling, if plastered, should be subse- 
quently treated with a lime-wash. Especial care must be taken to wash 
away all dust from window-ledges and other places where it may have settled, 
and thoroughly to cleanse crevices and out-of-the-way places. After this 
application of the disinfecting solution, and an interval of twenty-four hours 
or longer for free ventilation, the floors and wood-work should be well scrubbed 
with soap and hot water, and this should be followed by a second, more pro- 
longed exposur > to fresh air, admitted through open doors and windows. 

As an additional precaution, fumigation with sulphurous-acid gas is 
to be recommended, especially for rooms which have been occupied by patients 
with small-pox, scarlet fever, diphtheria, typhus fever, and yellow fever. But 
fumigation with sulphurous-acid gas alone, as commonly practiced, cannot be 
relied upon for disinfection of the sick-room and its contents, including bed- 
ding, furniture, infected clothing, etc., as is popularly believed. 



lft Solutions of corrosive sublimate should not be placed in metal re- 
ceptacles, for the salt is decomposed and the mercury precipitated by contact 
with copper, lead, or tin. A wooden tub or earthen crock is a suitable re- 
ceptacle for such solutions. 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 455 

When fumigation is practiced, it should precede the general washing 
with a disinfecting solution heretofore recommended. To insure any results 
of value, it will be necessary to close the r partment to be disinfected as com- 
pletely as possible by stopping up all apertures through which the gas might 
escape, and to burn not less than 3 pounds of sulphur for each 1000 cubic 
feet (l 1 /^ kilogrammes to 28 cubic metres) of air-space in the room. To 
secure complete combustion of the sulphur, it should be placed, in the form 
of powder or small fragments, into a shallow iron pan, which should be set 
upon a couple of bricks in a tub partly filled with water, to guard against 
fire. The sulphur should be thoroughly moistened with alcohol before ignit- 
ing it. 11 

Disinfection of Privy-vaults, Cess-pools, etc. — When the excreta (not 
previously disinfected) of patients with cholera or typhoid fever have been 
thrown into a privy-vault this is infected, and disinfection should be resorted 
to as soon as the fact is discovered, or whenever there is reasonable suspicion 
that such is the case. It will be advisable to take the same precautions with 
reference to privy-vaults into which the excreta of yellow fever have been 
thrown, although we do not definitely know that this is infectious material. 

For this purpose the standard solution of chloride of lime may be used 
in quantity proportioned to the amount of material to be disinfected, but 
where this is considerable it will scarcely be practicable to sterilize the whole 
mass. The liberal and repeated use of this solution, or of a 5-per-cent. solu- 
tion of carbolic acid, will, however, disinfect the surface of the mass, and is 
especially to be recommended during the epidemic prevalence of typhoid fever 
or of cholera. 

All ex ^osed portions of the vault, and the woodwork above it, should 
be thoroughly washed down with the disinfecting solution. Instead of the 
disinfecting solutions recommended, chloride of lime in powder may be daily 
scattered over the contents of the privy-vault. 

Disinfection of Ingesta. — It is well established that cholera and typhoid 
fever are very frequently, and perhaps usually, transmitted through the 
medium of infected water or articles of food, and especially milk. Fortunately, 
we have a simple means at hand for disinfecting such infected fluid. This 
consists in the application of heat. The boiling temperature maintained for 
half an hour kills all known disease-genns. So far as the germs of cholera, 
typhoid fever, and diphtheria are concerned, there is good reason to believe 
that a temperature considerably below the boiling-point of water will destroy 
them. But in order to keep on the safe side, it is best not to trust anything 
short of the boiling-point (100° C. = 212° F.) when the object is to disinfect 
food or drink which is open to the suspicion of containing the germs of any 
infectious disease. During the prevalence of an epidemic of cholera it is well 
to boil all water for drinking purposes. After boiling, the water may be 
filtered, if necessary, to remove sediment, and then cooled with pure ice if 
desired. 



11 Liquid anhydrous sulphur-dioxide may be used, and will probably give 
better results than combustion of sulphur. 



456 TEXT-BOOK OF HYGIENE. 

In recent years formaldehyde gas has taken the place of sulphur 
for aerial disinfection of rooms, fomites, etc. The following is freely 
quoted from a circular issued by the Illinois State Board of Health : — 

Formaldehyde (otherwise known as methyl aldehyde, formic- 
aldehyde and "formalin") exists in several forms, but is principally 
known as gas. Its germicidal properties were not recognized until 
1886, and were not put to use until 1890. The formaldehyde gas is 
the vapor of wood alcohol which has undergone a chemical change. 
The gas is produced by passing the vapor of wood alcohol over plati- 
num or platinized carbon in an incandescent state. Many portable 
apparatus for the production of formaldehyde gas directly from wood 
alcohol have been devised during the past seven or eight years, but 
none have proved satisfactory. 

The aqueous solution of formaldehyde gas, known as formalde- 
hyde or formalin, is a 40-per-cent. solution of the formaldehyde gas 
in water. Many of the commercial preparations do not contain- 40 
per cent, of formaldehyde. The concentration of the solution can 
not exceed 40 per cent. This preparation, if properly made, is a pow- 
erful bactericide and is preferable to corrosive sublimate as a germi- 
cide, cost not considered, although it is much slower in action. Sev- 
eral processes have been devised for the liberation of formaldehyde 
gas from its watery solution. The solution when exposed to the air 
gives off a considerable quantity of the gas, especially when sprayed 
on large surfaces. If sprayed on blankets or sheets, or articles of 
clothing, hung in the room or on the walls, the liberation of the gas 
will be so rapid as to compel the operator to leave the room. These 
facts have given rise to the belief that exposure of the gas in this 
manner will be sufficient to cause disinfection. The results, however, 
do not confirm this. There is much uncertainty as to the amount of 
gas which is evolved, and the behavior of the gas is at times very 
capricious. 

The most common method of obtaining formaldehyde gas from 
the watery solution at the present time is by means of apparatus 
designed to regenerate the gas by boiling the solution under pressure. 
Many generators operating on this princip^ are to be found on the 
market. Several of these are complicated machines requiring skill to 
properly operate. As some of the generators require constant atten- 
tion, it has been found necessary to place them outside of the apart- 
ment being disinfected and to pass the gas into the room by means of 
a tube run through a keyhole. The diffusion of the gas produced in 
this way is slow, particularly in large areas, tending to concentration 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 457 

at a few points and to the formation of paraformaldehyde. This 
method of disinfection cannot be recommended. 

With the Schering method of disinfection, which consists in the 
rapid evaporation of paraform pastilles, said to contain 100 per cent, 
pure formaldehyde, many tests have been made by the Illinois State 
Board of Health during the past five years. The results were gen- 
erally satisfactory, when the gases evolved were thoroughly mixed 
with the watery vapor. This method, however, is expensive; much 
care must be used in the working of the generator, and it has been 
found very difficult after disinfection to rid the premises of the gas. 
In one of the experiments the vapor ignited. The experiments were 
conducted with the Schering formalin disinfector (not the lamp) 
manufactured by Schering & Glatz, New York. 

Formaldehyde candles, which are composed of a variable amount 
of paraformaldehyde, pressed in cylindrical form in a tin container, 
are now offered to physicians and health authorities as a means of 
disinfection. It is claimed that, by burning the paraform, the heat 
produced causes the solid to revert to the gaseous form. No depend- 
ence whatever should be placed on these candles. 

The evaporation of the solution of formaldehyde by means of 
heat in an ordinary kettle is one of the simplest methods of disin- 
fection with formaldehyde, and as a result has proven the most 
effective. This is termed the Breslau method. Many health authori- 
ties have testified to its efficiency during the past seven years. 

While the results obtained with some of the methods of formalde- 
hyde disinfection formerly suggested have been generally satisfactory, 
failures were at times experienced when the conditions were appar- 
ently ideal; while under unfavorable conditions of temperature and 
humidity, ineffective disinfection was of frequent occurrence. 

Becently an exceedingly simple method of generating the gas by 
pouring formaldehyde solution over the crystals of potassium perman- 
ganate in an open vessel has been suggested, and gives promise of 
overcoming the objections which have stood in the way of the more 
general adoption of formaldehyde as a disinfecting agent. This 
method primarily offered the advantages of absolute simplicity in 
operation, requiring no special apparatus and no fire. In addition 
to this, exhaustive experimental work has demonstrated that, in prac- 
tical disinfection, the method is unusually efficient, the effectiveness 
seeming to depend less upon the conditions of humidity and tempera- 
ture than that of any other method. 

The only apparatus required is a large, open vessel, protected by 



458 TEXT-BOOK OF HYGIENE. 

some non-conductive material to preserve the heat within. An ordi- 
nary milk-pail, set into a pulp or wooden bucket, will answer every 
purpose, although a special container, devised for physicians and 
health officers, will be found of considerable advantage. This con- 
tainer or generator consists of a simply constructed tin can with 
broad, flaring top. Its full height is 151/2 inches, the height to the 
flaring or funnel-shaped top being about 8 inches. The lower or 
round section is 10 inches in diameter, while the funnel is Vty% inches 
in diameter at the top. This container is made of a good quality of 
tin, is supplied with a double bottom with i/^-inch air-space between 
the layers of tin, and is entirely covered on the outside with asbestos 
paper. The asbestos paper and double bottom serve to effectively 
retain the heat which is generated by the vigorous chemical reaction 
occurring within the generator and which is essential to the complete 
production and liberation of the gas. The special container can be 
made by any tinner of ordinary intelligence and costs but a few 
dollars. 

With the room sealed, as is essential to any form of aerial disin- 
fection, the crystals of potassium permanganate (3% ounces to each 
1000 cubic feet of air-space) are placed in the container. Over this 
salt is poured "formalin" or the 40-per-cent. aqueous solution of for- 
maldehyde (1 pint for every 1000 cubic feet of air-space). The for- 
maldehyde gas is promptly liberated by the vigorous chemical reac- 
tion of the formalin and the potassic salt and rises from the generator 
in immense volume in the form of an inverted cone. It is conse- 
quently essential that all preparations be made in advance and that 
the operator leave the room at once on the combination of the two 
chemicals. 

The doors or windows of exit should be promptly closed and 
sealed and the room left closed for at least six hours. 

The results obtained by this method in experiments conducted in 
the laboratories of the Illinois State Board of Health, under vary- 
ing atmospheric conditions, and with a rather wide range of tempera- 
ture, prove the method peculiarly effective, while the simplicity of 
the operation, the small expense of the apparatus (in fact, its success- 
ful operation without apparatus of any kind, if necessary), and the 
moderate cost of operation serve to commend it. 

However, even this method is not entirely free from danger of 
fire. Dr. C. T. White, while experimenting on disinfection, observed 
that in some instances spontaneous combustion of the formaldehyde 
gas takes place after the addition of the formaldehyde to the per- 



ANTISEPTICS, DISINFECTANTS AND DEODORANTS. 



459 



manganate of potash. Mr. C. H. La Wall, who investigated this 
phenomenon, ascribes it to the rapid formation of heat in the pres- 
ence of organic matter, and suggests the employment of small quan- 
tities of permanganate, not over 4 to 8 ounces to a charge, placed in 
several containers surrounded with large cones containing water. 
There should be no flame in the room. 

The following substances are antiseptics, but in the strength 
given cannot be depended upon as disinfectants: — 



Table LVIII. 

Thymol 1 : 80,000. 

Bichloride of mercury 1 : 40,000. 

Oil of mustard 1 : 33,000. 

Acetate of alumina 1 : 6310. 

Bromine 1 : 5597. 

Picric acid 1 : 5000. 

Iodine 1 : 4000. 

Sulphuric acid 1 : 800-1 : 3353. 

Permanganate of potassium 1 : 3000. 

Camphor 1 : 2500. 

Eucalyptol 1 : 2500. 

Chromic acid 1 : 2200. 

Chloride of aluminum 1 : 2000. 

Hydrochloric acid 1 : 1700. 

Benzoic acid 1 : 1439. 

Quinine 1 : 1000. 

Boric acid 1 : 200-1 : 800. 

Salicylic acid 1 : 200-1 : 800. 

Carbolic acid 1 : 500. 

Sulphate of copper 1 : 400. 

Nitric acid 1 : 400. 

Biborate of soda 1 : 200. 

Sulphate of iron 1 : 200. 

Creasote 1 : 200. 

Arsenious acid 1 : 100. 

Pyrogallic acid 1 : 62. 

Tr. chloride of iron 1 : 25. 

Alcohol 40 to 95 per cent. 



The agents mentioned in the above list may all be used with 
satisfactory results in surgical and obstetrical practice as antiseptics, 
but it must be borne in mind that the great danger in treating wounds 
comes from carrying infectious particles to them in the hands or in- 
struments of the operator. In order to render these aseptic the most 
thorough measures of disinfection, such as heat, strong chemical dis- 



460 TEXT-BOOK OF HYGIENE. 

infectants, and physical as well as chemical and biological cleanliness 
are indicated. In a surgical wound, or in the vagina and uterus of the 
parturient woman, the use of antiseptics is entirely secondary to dis- 
infection, under which may primarily be understood rigid cleanliness. 

In public and private sanitation, antiseptics have, as in prac- 
tical surgery, a subordinate importance. 

Deodorizers are sometimes useful in sanitary practice, but care 
must be taken not to look upon deodorization as equivalent to disin- 
fection. Among the most useful deodorizers are chloride of zinc, 
chloride of lime, permanganate of potassium, and a number of the 
agents mentioned in Table LVIII. 



QUESTIONS TO CHAPTER XVIII. 
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 

What is an antiseptic? How may it be used? Is it necessarily a dis- 
infectant? Why? Is a disinfectant an antiseptic? Why? Why must disin- 
fection be thorough to be of any value? What is necessary that there may be 
disinfection? How is the term often popularly, but incorrectly, used? 

What is the essential difference between a disinfectant, and a deodorant? 
What is a germicide? What is the true test of the value of a disinfectant? 
Have deodorants as such any real sanitary value? How do disinfectants differ 
in relation to disease-germs? How do the latter differ in relation to the 
former? How may the products of putrefaction, fermentation, or decay act 
as disinfectants? How may the products of the disease-germs themselves act 
as antiseptics or disinfectants? 

How may disinfectants be classified? What are the most useful agents 
for destroying spore-containing infectious material? How should these be 
used? What do we call disinfection by fire or heat? What agents may be 
used to disinfect infectious matter not containing spores? Which are most 
efficacious? What is an essential factor in the successful use of all disin- 
fectants ? 

In what diseases may the excreta be infected? What disinfectants may 
be used for excreta in the sick-room? In cess-pools? Why is mercuric chlo- 
ride not so efficacious here? What is the objection to the use of carbolic acid 
in typhoid fever? Why is chlorinated lime such a valuable disinfectant? 
How much chlorine should it contain? How should it be prepared? What is 
"milk of lime," and what value has it as a disinfectant for excreta? 

How may soiled underclothing, bed-linen, etc., be disinfected? How long 
should clothing be boiled in order to thoroughly disinfect it ? How may cloth- 
ing that would be harmed by immersion or chemicals be disinfected? What 
will be the effects on clothing of chlorine and sulphur gases? How may mat- 
tresses, blankets, etc., be disinfected? How long should the active process 
require ? 

What are some of the best disinfectants for use on the person? How 
may the danger of infection from a case of scarlet fever, small-pox, etc., be 
lessened? How should the bodies of those dead of infectious diseases be 
cared for? 

What can be done in the way of disinfection during the occupancy of 
the sick-room? What are the only disinfectants available? What value will 
deodorants have here? What method is to be followed as soon as the sick- 
room is vacated? Describe in detail. 

How may suspected merchandise and the mails be purified? What 
treatment should rags, etc., undergo? What is the method prescribed for 
the disinfection of a ship? For railway-ears? (See chapter on Quarantine.) 

How may articles of food and drink be made sterile and safe for use? 

How are antiseptics and disinfectants to be used, and for what purpose, 
in surgical and obstetrical practice? 

What is formaldehyde? What is the usual method of using formalde- 
hyde? What is the best method? 

(461) 



CHAPTER XIX. 

VITAL STATISTICS. 

The registration of vital statistics comprises the recording of 
the births, marriages, deaths, and diseases of a city, State, or nation. 
The facts thus secured must be properly classified and studied, for in 
no other way can a knowledge of the health of the inhabitants of 
such communities be obtained, and a real test is thus also furnished 
of the actual efficiency of sanitary undertakings. We may, indeed, 
study disease both by observation and experiment, thus learning that 
some maladies are more preventable than others and discovering their 
causes and means of prevention; and it is also true that for smaller 
or special communities, such as armies, navies, schools, or special 
classes of workmen, the health status may be obtained by direct 
methods but for large communities this is clearly impracticable, and 
the sanitarian is obliged to depend upon the census and the above- 
mentioned registration. 

The census is the count of its population which every civilized 
country makes at certain intervals, its returns also including particu- 
lars as to age, sex, race, occupation, etc. From the sanitarian's 
standpoint the age-record is, next to the population, the most im- 
portant return, for the death-rate varies most according to age. In 
this country the census now furnishes various data for localized "san- 
itary districts/' which may be even smaller than city wards, and these 
data afford the basis of comparison for variations in different parts 
of the same city and at different periods. 

The records of births, marriages, deaths, and diseases are obtained 
from the registration bureau, having been furnished the latter by 
duly authorized persons. The duty of registration should devolve 
upon the sanitary administration, such as the local or State board of 
health, this being the most appropriate medium for the collection 
of the information in question, while the individual returns should 
obviously be made to the bureau by the attending physician in each 
case. And, as these returns should be as accurate as possible, espe- 
cially as regards the diagnosis of preventable diseases and the deter- 
mination of the causes of death, both primary and secondary, it is 
one of the reasons why the State should carefully determine the 
(462) 



VITAL STATISTICS. 463 

qualifications of the physicians whom it allows to practice within its 
confines. 

From a sanitary point of view, the most important object of a 
registration of vital statistics is to "give warning of the undue increase 
of disease or death presumed to be due to preventable causes, and to 
indicate the localities in which sanitary effort is most desirable and 
most likely to be of use." 1 

It should be remembered that the following fundamental prin- 
ciples that underlie all statistical inquiries must be considered in 
the examination and analysis of any records or reports of the kind 
in question: — 

1. The numerical units with which the inquiry has to do must 
be constant, definite, and precise in character; if any lack these 
qualities, such should be omitted altogether. Hence the care that 
should be observed in the diagnosis of all cases. 

2. Groups of the numerical units must be so arranged that no 
unit is in more than one group at a time, and so that there can be 
no question as to the group in which each unit belongs. This is com- 
paratively simple where the grouping regards only the age, sex, race, 
etc., but the difficulty increases with the complexity of facts and re- 
quires special talent to properly analyze and develop all possible 
features. 

3. There must be a standard to express the relation of each 
group to the sum of the individual unit. This is usually 100, 1000, 
or some multiple of either. 

4. The relation of each, group to the total units is not a con- 
stant one unless all the factors which govern that relation are fixed 
and invariable — a condition which obviously does not obtain in vital 
statistics. The limit of variation in the relation of the component 
groups to the total, in two or more similar series, may, however, be 
expressed mathematically, and the variation itself will be found to 
diminish as the sum of individual units increases. Thus if, in the 
formula m + n = q, m be the number of units in one group and n 
the number in the other, the limit of variation will be indicated by the 
expression 2 "^ 15^ ; or, again, the relative value of two or more 
series is as the square root of the number of units in the respective 
series. 

The arithmetical mean is often used in vital statistics, and this 



l J. S. Billings, "Registration of Vital Statistics," American Journal of 
the Medical Sciences, vol. lxxxv, p. 37. 



464 TEXT-BOOK OF HYGIENE. 

will always approximate the invariable if the number of units is 
sufficient, but it must be remembered that the relation expressed by 
the average in one case cannot be predicated positively of any other. 
As, Dr. Guy says. "Averages are numerical expressions of probabilities; 
extreme values are expressions of possibilities." 

The graphic representation of statistical results is of advantage, 
since it brings their salient features clearly before the attention of 
the observer. 

The numerical units with which we are cencerned in vital statis- 
tics are persons, either living or dead, and these are divided into 
groups, according to age, sex, race, etc. Populations tend naturally 
to increase, the natural increment being measured by the difference 
in the number of births and deaths ; but the actual increment depends 
upon how this is modified by the relation between immigration and 
emigration. If these factors were all constant, the population would 
increase in geometrical progression; but as this is not so it cannot 
be exactly determined for periods other than those in which the cen- 
sus is taken. However, in determining the population for years 
other than census years, it is customary to assume that the same rate 
of increase continues as prevailed between the last two censuses, and 
to calculate the population therefrom by means of geometrical pro- 
gressions or logarithms. The number of houses in a city will help 
to determine the approximate population, for the average number of 
persons to the house in any city remains about the same from year 
to year. Such counts, as well as police censuses, are, however, almost 
always too high. In small and slowly-growing districts one-tenth of 
the difference in population of the last two censuses may be taken for 
each year since the last census. The population is always counted 
and annual birth- and death- rates calculated in this country for the 
middle of the year. 

REGISTRATION OF BIRTHS. 

The collection of data for an accurate registration of births is 
much more difficult than the record of deaths. Instead of requiring 
physicians and midwives in attendance at the confinement to report 
births, it would be more equitable and probably more effectual to com- 
pel the parents, under penalty for failure, to record the birth of 
each child at the board of health. The items usually included in 
birth returns are: date and place of birth, sex and color of child, 
names of father and mother, parents' nativity and age, and father's 



REGISTRATION OF DISEASES. 4G5 

occupation. Sometimes the residence of the mother, number of chil- 
dren previously borne by the same mother, whether the child is 
legitimate or not, and various other details are also added. It is evi- 
dent that for sanitary purposes most of this information is entirely 
irrelevant. It seems to the author that, for the purpose of the sani- 
tarian and medical statistician, the date and p^ce of birth, sex and 
color of the child, and age, nativity, and occupation of both parents 
are sufficient. 

REGISTRATION OF MARRIAGES. 

The record of marriages is of no interest to the sanitarian. If, 
however, the registration could be made by a competent medical man, 
and the physical condition of the contracting parties noted, valuable 
deductions might be made in time, especially if the parties themselves 
and their offspring could be kept under observation for many years. 
This, however, is so manifestly impracticable that it barely deserves 
notice in this place. 

REGISTRATION OF DISEASES. 

As has been seen in Chapter XIX, a large class of diseases are 
communicable from one individual to another, either directly, by 
contact, or mediately, by infection. In large communities it is there- 
fore important that the sanitary authorities should possess informa- 
tion of the presence and prevalence of these diseases, in order that 
measures may be instituted for their restriction. It is true that in 
most cases the registration of deaths gives but too mournful evidence 
of the more fatal of the diseases of this class, but destructive epi- 
demics could probably be frequently averted if preventive measures 
could be enforced early. Besides, in the case of dengue and epidemic 
influenza the death-rate may be so small that, if the registration of 
deaths were alone depended upon, no evidence whatever might be 
attainable of the epidemic prevalence of such diseases. 

The registration of prevailing diseases is, therefore, one of the 
most important duties of the registrar of vital statistics. Prompt 
notices of all cases of infectious, miasmatic, or contagious diseases 
coming under their professional notice should be required of all 
physicians. It is unquestionably just, however, that the plwsicians 
required to perform this duty should be properly compensated by the 
public, whose interests they serve. 

30 



466 TEXT-BOOK OF HYGIENE. 

REGISTRATION OF DEATHS. 

The data entered upon the record of death should comprise the 
name, age. sex, color, nativity, descent, occupation, and civil con- 
dition of decedent, with date, place, and cause of death. Under the 
heading "Descent" the birthplace of each parent should be given. 
Occupation should be accurately specified. The place of death should 
indicate the exact locality (number of street) where it occurred. 
Both proximate and predisposing causes of death should be entered, 
and any complications which may have influenced the fatal termina- 
tion should be noted on the record. 

The record should be in the possession of the local health author- 
ity before a permit for the burial of the deceased is granted. If this 
is not insisted upon, the report will soon be omitted and the registra- 
tion become defective. In fact, any system that puts off the collecting 
and recording of the death returns until the end of the year will 
fail to register from 25 to 40 per cent, of the number. 

DEATH=RATE AND BIRTH=RATE. 

In order to calculate the annual death-rate of a place two facts 
are required to be known: first, the acutal or estimated population 
(generally obtained, as indicated, from the census), and, second, the 
number of persons who died in the district during the year. The 
number of deaths is divided by the population, which gives the death- 
rate for each individual for the year. To find the death-rate per 
1000 the rate as found above is multiplied by 1000. Thus, the total 
number of deaths in the city of Philadelphia during 1893 was 23,- 
655, and the estimated population 1,115,562. The death-rate for 
the year was 21.20 per 1000, obtained as follows: — 

23,655 X 1000 

= 21.20 per M. 

1,115,562 

To calculate the annual death-rate per 1000 of a place from the 
returns for one week, the weekly population is first ascertained and 
then the number of deaths for the week divided by the weekly popu- 
lation and the quotient multiplied by 1000. The following example 
will render this clear: — 

The exact number of weeks in a year is 52.17747. The total 
population is divided by this number, giving the weekly population. 
This gives for Philadelphia, assuming the above estimate to be correct, 
a weekly population of 21,381. For the week ending June 3, 1893, 



DEATH-RATE A^'D BIRTH-RATE. 467 

the deaths in that city numbered 388. The annual death-rate per 
1000 — that is to say, the number of deaths in each 1000 of popula- 
tion, if the same rate be maintained throughout the year — is ob- 
tained as follows: — 

388 X 1000 

=18.15 per M. 

21,381 

The daily death-rate is obtained in a similar manner, the divisor 
for obtaining the daily population being 365, 24226, and the monthly 
population is found by multiplying the daily population by the num- 
ber of days in the respective months. But it should be remembered 
that these rates for such short periods cannot by any means accurately 
indicate the actual annual rate, and that they are to be used only for 
comparing the rates for similar periods at different seasons, etc. ; 
otherwise, with such large populations and such short periods the 
probabilities of error are too great for the results to be of any value. 

The annual zymotic or infectious death-rate, or that for any one 
disease, is obtained in the same manner as the general annual death- 
rate, and likewise the birth-rate. Or, to find the annual death-rate per 
1000 of population for this class of diseases, the following calculation 
may be made. Thus, out of the above 388 deaths, 84 were from in- 
fectious diseases: — 

84 X 1000 

=3.93 per M. per annum. 

21,381 

Or, if the percentage of deaths from infectious diseases be de- 
sired, the procedure would be as follows : — 

84 X 100 

— 21.65 per cent, of the total deaths. 

388 

As an exception to the rule, the rate of infant mortality or in- 
fantile death-rate is indicated by the ratio of deaths of children under 
one year to the number of births recorded for the year, and is found 
by multiplying the number of infantile deaths by 1000 and dividing 
by the number of births; for example, for the }^ear just quoted the 
decedents under one year of age numbered 5710; the total number 
of births for the same year was 30,737. Hence — 
5710 X 1000 

3Q737 = 185-77 per 1000 births. 

Nineteen of the 388 deaths for the week ending June 3, were 
of colored persons. The death-rate of these to the total population is 
found in a similar manner to the above ; but if it is desired to ascer- 



468 TEXT-BOOK OV BYGIENE. 

tain the death-rate o\' the colored population alone, the weekly colored 
population must first be obtained, and the rate calculated from this 
by the above formula. 

There are a number of factors that affect the general death-rate, 
such as the size of the community, habits of life, age- and sex- dis- 
tribution, occupation of the bulk of the inhabitants, etc. For the 
country and small towns the rate should be from 9 to 16 per 1000, 
gradually increasing until for the largest cities it amounts to from 
18 to 21 per 1000. Death-rates reported below these figures would 
indicate that all the deaths had not been recorded, or that the popula- 
tion had been overestimated; rates a'bove would be evidence that 
there were special causes at work demanding sanitary investigation 
and improvement. 

Among the causes that make the mortality among infants and 
children high are parents too young or sickly, hereditary taints, un- 
healthy environments, improper and insufficient food and clothing, 
and, not rarely, infant life-insurance. It is simply the manifestation 
of one of the workings of the law of "the survival of the fittest." 
In localities newly settled, where the proportion of adults to children 
is greater than the normal, the death-rate is naturally lower ; though 
it is conceivable that the occupations in which the adults engaged and 
the vicissitudes and unsettled conditions, both sanitary and social, of 
a new settlement might cause or tend to cause a very high mortality. 
Since more males die than females, the sex-distribution will also 
have its influence on the death-rate, especially if there is a prepon- 
derance of one sex over the other in any locality. 

Many conditions affect the death-rate from the different diseases, 
namely, age, race, sex, occupation, environment, seasons, temperature, 
etc. The zymotic death-rate, and especially that part of it due to. 
typhoid fever, may be an extremely good index of the actual value and 
benefit of sanitary improvements and the enforcement of hygienic 
laws. Thus, the mortality from typhoid fever in England and Wales 
has been reduced more than 50 per cent, since the introduction and 
enforcement of the general sanitary regulations in that kingdom. 

On account of lack of registration of all cases of disease, it is 
practically impossible to determine the sick-rate of a community or 
population; but it is said that the sickness of a community amounts 
to the disablement of one person for two years for every death, and 
the records of English beneficial societies seem to show that each 
member averages about one and one-half weeks' sickness annually. 

The following definitions are introduced because the terms are 



DEATH-RATE AiND BIRTH-RATE. 469 

frequently used in discussions of vital statistics, and especially of life- 
insurance. The comparative mortality figure indicates that the 
same number of persons that gave 1000 deaths in the whole population 
would furnish the deaths indicated by the figure in the city or locality 
in question. Thus, if the comparative mortality figure of a place 
is 925 and the death-rate of the country is 20, there are 1000 deaths 
for every 50,000 of the whole population and the death-rate of the 
given place is 18.5. For 20 : 1000 : : x : 925 and x = 18.5. 

The average or mean age at death is ascertained by adding up the 
ages of all the decedents and dividing the sum by the number of 
deaths. Unless it is derived from the life-tables of an entire gen- 
eration, it is not a fair index of longevity or of sanitary conditions, 
since it is affected considerably by the age-distribution of the popula- 
tion from which it is compiled. 

The expectation of life at any age is the average number of years 
which persons of that age may expect to live. For the newborn it is 
the same as the mean duration of life, and, "as applied to commu- 
nities, it is the mean life-time of a generation of persons traced by the 
life-table method from birth to death, and is the only true test of the 
health of populations." A life-table is computed from the number 
and ages of the living and of those that die, these factors being ob- 
tained from the average population for each age and sex, and from 
the total death-returns between two or more censuses. It is, as Dr. 
Farr says, "a barometer which indicates the exact measure of the 
duration of life under given circumstances, and is indispensable in 
gauging the influence of sanitary or insanitary conditions." 

It is only when the population does not vary as to age- or sex- 
distribution that the mean duration of life is identical with the aver- 
age age at death. Otherwise, for any person at any age it is the same 
as the expectation of life. The probable duration of life is equivalent 
to the age at which any number of newborn children will be reduced 
one-half, the same conditions persisting. With a million children as 
a basis, it is less than forty-five years for males and about forty-seven 
years for females. 

It will be evident, on a little thought, that there must be many 
sources of error in calculations based upon such uncertain data as 
are derived from the registration of births and deaths as conducted 
in most cities in this country. Besides, the subject of vital statistics 
is essentially abstruse, and requires no little readiness in mathematics 
to appreciate its profounder bearings. Hence, in the foregoing 
chapter, no attempt has been made to penetrate beyond the imme- 
diate practical aspects of the questions involved. 



QUESTIONS TO CHAPTER XIX. 

VITAL STATISTICS. 

What is comprised in the registration of vital statistics? How are they 
to be made of use? Of what value are the recorded statistics to the sanitarian? 
How else may disease be studied? Why may not the same methods of deter- 
mining the general health be applied to large communities as to small ones? 

What is the census? What returns of interest to the sanitarian does 
it make? Which of these are the most important? Why? What is the 
advantage of furnishing returns for "sanitary districts," and what is meant 
by the latter? 

What returns are to be obtained from the registration bureau? Who 
furnishes these returns? Who should have charge of the registration? Why? 
W T hy should physicians make the returns? Why should the State take care 
in the licensing of physicians to practice? What is the most important object 
of the registration of vital statistics ? 

What are the fundamental principles underlying all statistical inquiry? 
What units or cases should be omitted? What renders the classification of 
groups difficult? What is the usual standard of comparison? When is the 
relation of component groups to the total constant? How may the probable 
limit of variation be determined? What tends to make the arithmetical mean 
approach the invariable? How may the relative value of different series of 
the same kind of cases be determined? What is the difference between aver- 
ages and extreme values ? Of what value is the graphic method of representing 
statistical results? 

What are the units of vital statistics? How may they be divided into 
groups? What is the natural increment of a population? How does this 
differ from the actual increment? If the factors were constant, how would 
a population increase? Why? Why cannot the population be determined 
exactly for intercensal periods? What is the usual and most accurate way 
of determining it? How else may it be estimated? What is the fault of 
counts made by local authorities or police censuses? At what time of the 
year is the count always made? For what time are annual death-rates, etc., 
calculated? 

Why is the collection of data for birth-records difficult? Who should 
make the return? What items are usually included in the returns? Which 
are the only ones of value to the sanitarian and medical statistician? Why 
is the record of marriages of no sanitary interest? How might it be made 
so? Is this practicable? 

What classes of diseases should be reported and recorded? Why? What 
epidemic diseases might escape notice by the statistician if only reported in 
death-returns? When should the returns of infectious diseases be made? 
Should there be any recompense for the returns to the physicians? 

(470) 



QUESTI0N8 TO CHAPTER XIX. 471 

What data should be given by a death-certificate? Which items should 
be accurately specified? What care should be taken in reporting the cause 
of death? When should the burial-permit be issued? 

What factors are required in order to calculate the death-rate of a 
locality? How is the death-rate for the year obtained? How may the annual 
death-rate of a place be calculated from the death-returns for one week ? What 
is the weekly and the daily population? How is the monthly population 
found? What is the objection to rates determined from returns for such 
short periods? Of what value are they? 

What is meant by the zymotic or infectious death-rate? How may it 
be determined? How is the percentage of deaths due to infectious disease 
determined? How is the rate of infant mortality determined? 

What factors affect the general death-rate? What is a fair death-rate 
for small communities? For large cities? What do higher rates than this 
usually indicate? What do lower ones? What causes make the mortality so 
high among infants and young children. What may make the death-rate of 
a community lower than the normal? What higher? How may sex-distribu- 
tion affect the death-rate? What conditions or factors affect the mortality 
from the different diseases? How may the zymotic death-rate be an index of 
the value of sanitary measures? 

Why is it so difficult to determine the sick-rate of a community? How 
may the total amount of sickness be approximately estimated? 

What is meant by the comparative mortality figure ? What by the aver- 
age age at death ? Is this necessarily a fair index of longevity ? What affects 
it? What is meant by the expectation of life? Of what value is it when 
applied to communities? What is a life-table, and how is it computed? Of 
what value is it to sanitarians? When is the mean duration of life identical 
with the average age of death ? What is meant by the probable duration of 
life? Why are calculations of vital statistics liable to be unreliable or in- 
accurate 1 



CHAPTER XX. 

QUARANTINE. 

By quarantine is meant the adoption of restrictive measures to 
prevent the introduction of diseases from one country or locality into 
another. The term itself conveys no definite idea, being derived 
through the Italian from the Latin "quadraginta," meaning "forty" 
and implying forty days — the period of detention imposed on vessels 
by the first quarantines established at Venice in 1403. The old sig- 
nificance of the term is entirely lost in its present application, which 
is quite general. Thus, besides regular maritime quarantine, mention 
is often made of land, railroad, cattle, shot-gun, house, and even room 
quarantine. 

The name of a disease or article of merchandise may be used 
in a prefix, as in "yellow-fever quarantine," small-pox, cholera, or 
rag quarantine. Moreover, quarantines are described as properly be- 
ginning at the port of departure, and as quarantine of inspection 
only, the fumigation and detention being imposed at some neighboring 
station. The term, therefore, is applied not only to establishments, 
but indifferently to persons, animals, diseases, localities, and measures. 

There is need of a clear understanding with regard to the term, 
for when, as occasionally, quarantine is ridiculed, or the assertion 
is made that the English disbelieve in quarantine, a wrong impression 
will be received, unless it is understood that only particular and 
obsolete forms of quarantine are meant, and not quarantine in the 
broad sense just mentioned. 

The subject admits of two natural divisions — maritime and land 
quarantine; but before describing them attention is called to the 
following table, containing a list of diseases that are ordinarily 
found in official quarantine proclamations: — 

This list illustrates the growth of the sanitary idea and belief 
in quarantine. For many years, as now at some ports, the list was 
limited to yellow fever, typhus, cholera, and small-pox. It was thus 
limited at Boston prior to 1881, since which date diphtheria, scarlet 
fever, typhoid fever, and measles have been added. The statutes of 
New York define as quaran tin able fellow fever, measles, cholera, 
typhus or ship fever, small-pox, scarlatina, diphtheria, relapsing fever, 
and any disease of a contagious, infectious, or pestilential character 
(472) 



FOREIGN QUARANTINE. 



473 



Table LIX. 

Quarantinable Diseases. 



Plague 

Yellow fever . . 

Cholera 

Typhus fever. . 

Small-pox 

Measles 

Diphtheria . . . 
Typhoid fever. 
Scarlet fever . . 
Relapsing fever 

Dengue 

Leprosy 





Period of Incubat 


Shortest 


Longest 


Usual 


3 


8 


3 to 5 


1 


7 


n 


2 


14 


2 to 4 


1 


21 


5 to 14 


5 


20 


10 


7 


14 


10 


2 


10 


2 to 5 


7 


28 


21 


1 


"Weeks 


4 to 7 


5 


7 


6 


1 


10 


5 



Authority and Remarks. 



Kitasato. 

Da Costa, Bartholow, 

Reed, Carver. 
Bartholow. 
Br i stow. 
Da Costa. 
Da Costa. 
Bartholow. 
Bartholow. 
Da Costa. 
Bartholow. 
Bartholow. 
Undetermined. 



which shall be considered by the health officer dangerous to the 
public health." 

At Gibraltar, the English sanitary authorities include dengue 
and epidemic rose-rash among the diseases subject to their quarantine 
regulations. 

Another addition to the list in this country is leprosy, to prevent 
the introduction of which, and in accordance with a resolution of the 
American Public Health Association, a prohibitory circular was issued 
by the Surgeon- General of the Marine-Hospital Service, December 
23, 1889. 

Other diseases which may properly call for quarantine are mumps, 
whooping cough, chicken-pox, epidemic dysentery, glanders, tetanus, 
beriberi, epidemic influenza, and pulmonary tuberculosis. 

Influenza may be considered quarantinable under certain circum- 
stances, a successful quarantine being reported by Dr. Trudeau, whose 
cottage sanitarium, in the Adirondacks, New York, was thus kept 
exempt during the epidemic of 1890. 

With regard to pulmonary tuberculosis the ground is taken by 
the writer that this disease, at least among immigrants, should be 
excluded from the United States by quarantine. 



FOREIGN QUARANTINE. 

The object of maritime quarantine being protection against the 
importation of contagious or infectious disease, chiefly from abroad, 



47-i TEXT-BOOK OF HYGIENE. 

through the medium of vessels, their crews, passengers, and cargoes, 
it is most logical that restrictive measures should begin at the port 
of departure. Following are the regulations prepared by the Surgeon- 
General of the Public Health and Marine-Hospital Service of the 
United States and promulgated by the Secretary of the Treasury, 
April 1, 1903. All quarantine regulations are subject to occasional 
revision under the Act of Congress approved February 15, 1893. 

QUARANTINE REGULATIONS. 

QUARANTINABLE DISEASES. 

1. For the purpose of these regulations the quarantinable dis- 
eases are cholera, yellow fever, small-pox, typhus fever, leprosy, and 
plague. 

Foreign Kegulations. 

Quarantine Regulations to be Observed at Foreign Ports and at 
Ports in the Possessions andDependencies of the United States. 

Bills of Health. 

2. Masters of vessels departing from any foreign port, or from 
any port in the possessions or other dependencies of the United 
States for a port in the United States or its possessions or other de- 
pendencies, must obtain a bill of health, in duplicate, signed by the 
proper officer or officers of the United States as provided for by law, 
except as provided for in paragraph 4. 

The following form is prescribed: — 

Form No. 1937. 
United States Bill of Health. 



Name of vessel, . Nationality, . Rig, . Master, 



Tonnage, gross, ; net, . Iron or wood. Number of compartments 

for cargo, ; for steerage passengers, ; for crew, . 

Name of medical officer, . 

Number of officers, . 



Number of members of officers' families, 
Number of crew, including petty officers, 

Number of passengers, cabin, . 

Number of passengers, steerage, . 



Number of persons on board, all told, . 

Port of departure, . 

Where last from, . 

Number of cases of sickness and character, during last voyage, 



FOREIGN QUARANTINE. 475 

Vessel engaged in trade, and plies between and . 

Sanitary condition of vessel, . 

Nature, sanitary history, and condition of cargo, . 

Source and wholesomeness of water supply, . 

Source and wholesomeness of food supply, . 

.Sanitary history and health of officers and crew, . 

Sanitary history and health of passengers, cabin, . 

Sanitary history and health of passengers, steerage, . 

Sanitary history and condition of their effects, . 

Prevailing diseases at port and vicinity, . 

Location of vessel while discharging and loading — open bay or wharf, . 

Number of cases and deaths from the following-named diseases during the 
past two weeks: 

Yellow fever 

Asiatic cholera 

Cholera nostras or cholerine 

Small-pox 

Typhus fever 

Plague 

Leprosy 

Number of cases of sickness and character of same while vessel was in this 
port, . 

Any conditions affecting the public health existing in the port of departure 
or vicinity to be here stated, : . 

I certify that the vessel has complied with the rules and regulations made 
under the act of February 15, 1893, and that the vessel leaves this port bound 
for , U. S. of America, via . 

Given under my hand and seal this day of , 190 . 

( Signature of consular officer : ) , 



3. Vessels clearing from a foreign port or from any port in the 
possessions or other dependencies of the United States for any port in 
the United States, its possessions or other dependencies, and entering 
or calling at intermediate ports, must procure at all said ports a sup- 
plemental bill of health in duplicate signed by the proper officer or 
officers of the United States, as provided in the law. If a quarantin- 
able disease has appeared on board the vessel after leaving the original 
port of departure, or other circumstances presumably render the ves- 
sel infected, the supplemental bill of health should be withheld until 
such sanitary measures have been taken as are necessary. 

The following form is prescribed : — 

Supplemental Bill of Health. 

Port of . 

Vessel , bound from to , U. S. A. 

Sanitary condition of port, . 



476 



TEXT-BOOK OF HYGIENE. 



State diseases prevailing at port and in surrounding country, 



Number of eases and the deaths from the following-named diseases during 
the past two weeks: — 

Table LX. 

Table of Diseases. 



Yellow fever 

Asiatic cholera 

Cholera nostras, or 

cholerine 

Small-pox 

Typhus fever 

Plague 

Leprosy 



No. of 
Cases 



No. of 
deaths 



Remarks 

(Any condition affecting the public health existing 

in the port to be stated here.) 



Number and sanitary condition of passengers and crew landed at this port. 

Cabin, No. . Sanitary condition and history, . 

Steerage, No. . Sanitary condition and history, . 

Crew, No. . Sanitary condition and history, . 

Note. — If disembarked on account of sickness state disease, . 

Number and sanitary condition of passengers and crew taken on at this port, 
and sanitary condition of effects. 

Cabin, No. . Sanitary condition and history, . 

Steerage, No. . Sanitary condition and history, . 

Crew, No. . Sanitary condition and history, . 

Sanitary condition of effects, . 



Sanitary history of vessel since leaving last port. 
(Cancel Form A, B, or C, as the case requires.) 



no quarantinable disease has 
appeared aboard since leav- 
ing . 



Form. 

A. — To the best of my knowledge and belief — 

(Form A will be used at intermediate ports where 
the vessel does not enter and clear.) 

B. — I have satisfied myself that — 

(Form B will be used at intermediate por!s where J 
the vci-sel enters and clears. ) 

C. — Since leaving the following quarantinable disease has appeared 

on board , and I certify that the necessary sanitary measures have 

been taken. 

I certify also that with reference to the passengers, effects, and cargo taken 
on at this port, the vessel has complied with the rules and regulations made 
under the act of February 15, 1893. 

Given uncer my hand and seal this day of , 190 . 

( Signature of consular officer : ) , 



FOREIGN QUARANTINE. 477 

4. Under the act of Congress approved August 18, 1894, vessels 
plying between Canadian ports on the St. Croix River, the St. Law- 
rence River, the Niagara River, the Detroit River, the St. Clair River, 
and the St. Mary's River, and adjacent ports of the United States on 
the same waters; also vessels plying between Canadian ports on the 
following-named lakes, viz,, Ontario, Erie, St. Clair, Huron, Superior, 
Rainy Lake, Lake of the Woods, and Lake Champlain, and ports in 
the United States; also vessels plying between Mexican ports on the 
Rio Grande River and adjacent ports in the United States, are exempt 
from the provisions of section 2 of the act granting additional quar- 
antine powers and imposing additional duties upon the Marine-Hos- 
pital Service, approved February 15, 1893, which requires vessels 
clearing from a foreign port for a port in the United States to obtain 
from the consular or medical officer a bill of health. During the 
prevalence of any of the quarantinable diseases at the foreign port of 
departure, vessels above referred to are hereby required to obtain 
from the consular officer of the United States, or from the medical 
officer of the United States, when such officer has been detailed by the 
President for this purpose, a bill of health, or a supplemental bill 
of health, in duplicate, in the form prescribed by the Secretary of the 
Treasury. 

Inspection of Vessels Leaving Foreign Ports and Ports in the Pos- 
sessions or other Dependencies of the United States for Ports in 
the United States or its Possessions or other Dependencies. 

5. The officer issuing the bill of health shall satisfy himself, by 
inspection, if necessary, that the conditions certified to therein are 
true, and is authorized, in accordance with the law, to withhold the 
bill of health or the supplemental bill of health until he is satisfied 
that the vessel, the passengers, the crew, and the cargo have complied 
with all the quarantine laws and regulations of the United States. 

6. Inspection is required of — 

(a) All vessels from ports at which cholera, yellow fever, or 
plague prevails, or at which small-pox or typhus fever prevails in 
epidemic form. 

(b) All vessels carrying steerage passengers; but need only in- 
clude the inspection of such passengers and their living apartments, 
if sailing from a healthy port. 

7. Inspection of the vessel is such an examination of the vessel, 
cargo, passengers, crew, personal effects of same, •including examina- 
tion of manifests and other papers, food- and water- supply, the as- 



478 TEXT-BOOK OF HYGIENE. 

certainment of its relations with the shore, the manner of loading, and 
possibilities of invasion by small animals as will enable the inspecting 
officer to determine if these regulations have been complied with. 

8. When an inspection is required, it should be made by daylight, 
as late as practicable before sailing. The vessel should be inspected 
before the passengers go aboard, the passengers just before embarka- 
tion, and the crew on deck; and no communication should be had 
with the vessel after such inspection except by permission of the officer 
issuing the bill of health. 

Requirements with Regard to Vessels. 

9. Vessels, prior to stowing cargo or receiving passengers, should 
be mechanically clean in all parts, especially the hold, forecastle, and 
steerage; the bilges and limbers free from odor and deposit. The air 
streaks should be sufficient in number and open for ventilation. 

10. Any portions of the vessel liable to have been infected by any 
communicable disease should be disinfected before the issuance of the 
bill of health. 

11. The air-space, ventilation, food- and water- supply, hospital 
accommodations, and all other matters mentioned therein promotive 
of the health and comfort of the passengers must be in accordance 
with the provisions of the act of Congress approved August 2, 1882, 
entitled "An act to regulate the carriage of passengers by sea/ 7 

12. At ports where cholera prevails in epidemic form, special care 
should be taken to prevent the water- and the food- supply from 
being infected. The drinking-water should be boiled and the food 
thoroughly cooked and protected against contamination by flies, etc. 

13. At ports where yellow fever prevails, in addition to the other 
measures presented hereafter, precautions should be taken to prevent 
the introduction of mosquitoes on board the vessel. Water-tanks, 
water-buckets, and other collections of water about the vessel should 
be guarded in such a manner that they shall not become breeding- 
places for mosquitoes. Measures should also be taken to destroy 
mosquitoes that may have come on board. Baggage destined directly 
or indirectly for any State should be disinfected at the request of the 
health officer of said State. All baggage from such ports must be 
rigidly inspected and the exclusion of mosquitoes assured. 

14. At ports or places where plague prevails, every precaution 
must be taken to prevent the vessel becoming infected through the 
agency of rats, ante, flies, fleas, or other animals. At such ports or 
places the vessel should not lie at a dock, or tie to the shore, or anchor 



FOREIGN QUARANTINE. 479 

near any place where such animals may gain access to the vessel. In 
case cables are led to the shore they should be freshly tarred and 
provided with inverted cones or such other devices as may prevent 
rats and other animals passing to the ship. The introduction of 
vermin on board the vessel from lighters and all other sources should 
be guarded against. In such ports sulphur fumigation should be 
resorted to in the holds when empty and from time to time during 
loading in order to destroy vermin. 

15. At all infected ports or places, communication between the 
vessel and shore should be reduced to a minimum. 

16. Vessels carrying passengers from any port or place where 
quarantinable disease prevails in epidemic form should have one med- 
ical officer; and from ports where cholera or plague prevails in epi- 
demic form should have two medical officers if more than 250 passen- 
gers are carried. 

Cargo. 

17. Earth, loam, soft or porous rock should not be taken as bal- 
last at ports infected with cholera or plague. Street-sweepings, city 
cleanings, or anything containing organic refuse should not be taken 
as ballast from any port. Where practicable, hard rock or clean beach 
sand or sea-water ballast should be given preference. 

fc 18. Household goods, personal effects, bedding, and second-hand 
articles generally, coming from a district known to be infected with 
cholera, small-pox, typhus fever, or plague, or as to the origin of 
which no positive evidence can be obtained, and which the consular or 
medical officer has reason to believe are infected, should be disinfected 
prior to shipment. Measures should be taken with articles of this 
class from districts infected with yellow fever to insure their freedom 
from mosquitoes. 

19. New merchandise in general may be accepted for shipment 
without restriction, and articles of new merchandise — textile fabrics 
and the like — which have been packed or prepared for shipment in an 
infected port or place, with a special view to protect the same from 
moisture incident to the voyage, may be accepted and exempted from 
disinfection. 

20. Certain food products, viz., unsalted meats, sausages, dressed 
poultry, fresh butter, fresh milk (unsterilized), fresh cheese, coming 
from cholera-infected localities or through such localities, if exposed 
to infection therein, should not be shipped. Fresh fruits and vege- 
tables, from districts where cholera prevails, shall be shipped only 



4 SO TEXT-BOOK OF HYGIENE. 

under such sanitary supervision as will enable the inspector to certify 
that they have not been exposed to infection. 

21. All rags and textile fabrics used in the manufacture of paper 
and for other purposes which are collected, packed, or handled in any 
foreign port or place, with the exceptions as hereinafter specified, 
shall, prior to shipment to the United States, be subjected to disinfec- 
tion by # one of the prescribed methods. (Jute bags or bagging used 
in baling cotton, old rope, new cotton, or linen cuttings from factories 
not included.) The disinfection of the articles mentioned above shall 
be performed under the supervision of a United States consul or a 
medical officer of the United States, and a certificate in duplicate, 
signed by said consul or medical officer, shall be issued with each con- 
signment of same, which certificate shall identify the articles and state 
that they have been disinfected in accordance with the United States 
quarantine regulations. The original certificate of disinfection shall 
be attached to the consignee's invoice, and where the articles are car- 
ried by sea the duplicate certificate of disinfection shall be attached to 
the bill of health issued to the vessel conveying the same. 

Exceptions. — Such articles shipped from the dominion of Canada 
directly to the United States shall be exempt from this requirement 
if accompanied by affidavits demonstrating to the satisfaction of the 
collector of customs at the port of arrival that they have actually 
originated in Canada and have not been shipped from a foreign country 
to Canada, and thence shipped to the United States ; and further, that 
the port or place where collected or handled has been free from quar- 
antinable diseases for thirty days prior to shipment. 

22. New feathers for bedding, human and other hair (unmanu- 
factured), bristles, wool, hides not chemically cured, coming from a 
district where cholera or plague prevails, shall be refused entry into 
the United States until thirty days have elapsed since last exposure 
in case of cholera, and sixty days in case of plague, unless unpacked 
and disinfected. Feathers which have been used should be disinfected, 
and invariably by steam. 

Bristles which have been boiled, and wool and new feathers which 
have been packed in naphthalin preparatory to shipment, may be 
shipped without further treatment. 

Dry hides packed in naphthalin may be shipped as chemically 
cured hides. 

Unsalted green hides from a district where cholera prevails must 
not be shipped. 

23. The articles enumerated in the preceding paragraph coming 



FOREIGN QUARANTINE. 481 

from a district where small-pox, typhus fever, cholera, or plague pre- 
vails in epidemic form, should be refused shipment unless disinfected 
as hereinafter provided. 

24. Nothing in these regulations shall be construed to modify or 
affect in any way any existing restrictions promulgated by the secre- 
tary of the Treasury at the instance of the Bureau of Animal Industry, 
Department of Agriculture, regarding the importation of hides of 
neat cattle. 

25. Any covering, shipped from or through an infected port or 
place, and which the consul or medical officer has reason to believe 
infected, should be disinfected. 

26. Any article presumably infected, which can not be dis- 
infected should not be shipped. 

Passengers and Crew. 

27. Passengers, for the purposes of these regulations, are divided 
into two classes : cabin and steerage. 

28. When practicable, passengers should not ship from an infected 
port. 

29. No person suffering from a quarantinable disease, or scarlet 
fever, measles, diphtheria, or other communicable disease, should be 
allowed to ship. 

30. Steerage passengers and crew coming from cholera-infected 
districts should be detained five days in suitable houses or barracks 
located where there is no danger from infection, and all baggage 
disinfected. 

31. Steerage passengers and crew from districts not infected with 
cholera, shipping at a port infected with cholera, unless passed through 
without danger of infection and no communication allowed between 
such persons and the infected locality, should be treated as those in 
the last paragraph. 

32. Cabin passengers coming from cholera-infected districts em- 
barking at a clean or an infected port should produce satisfactory 
evidence as to their exact places of abode during the five days imme- 
diately preceding embarkation. And if it appears that they or their 
baggage have been exposed to infection, the baggage should be disin- 
fected and the passengers detained under medical supervision a suffi- 
cient time to cover the period of incubation since last exposure. 

33. Steerage passengers and crew who, in the opinion of the inspect- 
ing officer, have been exposed to the infection of yellow fever, should 



|S J TEXT-BOOK OF HYGIENE. 

be held under medical observation in a place free from danger of 
infection for a period of five days before embarkation. 

34. Steerage passengers and crew, coming from districts where 
small-pox prevails in epidemic form, or who have been exposed to 
small-pox, should be vaccinated before embarkation, unless they show 
evidence of having acquired immunity to small-pox by previous attack 
or recent successful vaccination. 

35. Steerage passengers and crew who, in the opinion of the in- 
specting officer have been exposed to the infection of typhus fever, 
should not be allowed to embark for a period of at least twelve days 
after such exposure and the disinfection of their baggage. 

36. Steerage passengers and crew who, in the opinion of the in- 
specting officer, have been exposed to the infection of plague should 
be held under medical observation in a place free from danger of 
infection for a period of seven days before embarkation, and their 
baggage disinfected. 

37. Cabin passengers coming from plague-infected districts, 
whether embarking at a clean or an infected port, should produce 
satisfactory evidence as to their exact places of abode during the seven 
days immediately preceding embarkation. And if it appears that they 
or their baggage have been exposed to infection the baggage should 
be disinfected and the passengers detained under medical supervision 
a sufficient time to cover the period of incubation since the last ex- 
posure. 

38. Should quarantinable disease appear in the barracks or 
houses in which passengers are undergoing detention, no passenger 
from said houses or barracks who has been presumably exposed to 
this new infection should embark until after the expiration of the 
period of incubation of the disease in question subsequent to the last 
exposure to infection and the application of all necessary sanitary 
measures. 

39. All baggage of steerage passengers destined for the United 
States should be labeled. If the baggage is in good sanitary condi- 
tion the label shall be a red label bearing the name of the port, the 
steamship on which the baggage is to be carried, the word "passed" 
in large type, the date of inspection, and the seal or stamp of the 
consular or medical officer of the United States. All baggage that has 
been disinfected shall bear a yellow label, upon which shall be printed 
the name of the port, the steamship upon which the baggage is to be 
carried, the word "disinfected" in large type, the date of disinfection, 
and the seal or stamp of the consular or medical officer of the United 



FOREIGN QUARANT I N E. 



483 



Port of departure 
Name of ship 



INSPECTION CARD. 

[Immigrants and Steerage Passengers.] 

Date of departure 

. Last permanent residence 



Name of immigrant 



Inspected and passed 



[Seal or stamp of consular or 
medical officer] 



Passed at quarantine, port of 
, United States. 



[Date.] 



Passed by Immigration Bu- 
reau, port of 



[Date.] 



[The following to be filled in by ship's surgeon or agent prior to or after embarkation.] 
Ship's list or manifest . No. on ship's list or manifest 



Berth No. 



$.2 8*2 



■6 . 



-a 

to C^ 



ic «c i^ cc oj o 



o a <n 2r° m. 

^ S >. = -a .2 ' 



VACCINATED. 

[Signature or Stamp.] 
[Reverse Side.] 

Keep this Card to avoid detention at Quarantine and on Railroads in 
the United States. 



Diese Karte muss aufbewahrt werden, um Aufenthalt an der Quaran- 
tine, sowie auf den Eisenbahnen der Vereinigten Staaten zu vermeiden. 



Cette carte doit etre conservee pour eviter une detention a la Quaran- 
taine, ainsi que sur les chemins de fer des Etats-Unis. 



Deze kaart moet bewaard worden, ten einde oponthoud aan de Quar- 
antijn, alsook op de ijzeren wegen der Vereenigde Staten te vermijden. 



Conservate questo biglietto onde evitare detenzione alia Quarantina 
e sulle Ferrovie degli Stati Uniti. 



Tento Ustek musite uschovati, nechcete-li ukaranteny (zastavenf 
ohledne" zjisteni zdravi) neb na draze ve spojenych statech zdrzeni byti. 



Tuto kartocku treba trimat' u sebe aby sa predeslo zderzovanu v 
karantene aj na zeleznici ve Spojench Statoch. 



484 TEXT-BOOK OF BYGIENE. 

States. It is understood, and it will be so printed on the blank, that 
the label is not valid unless bearing the consular or medical officer's 
stamp or seal. 

40. Each steerage passenger shall be furnished with an inspection 
card (see page 483). This card, stamped by the consular or medical 
officer, is to be issued to every member of a family as well as to the 
head thereof. 

41. In a port where any quarantinable disease prevails, the per- 
sonnel of vessels should remain on board during their stay in such port. 

42. Passengers and crews, merchandise and baggage, prior to 
shipment at a noninfected port, but coming from an infected locality, 
should be subject to the same restrictions as are imposed at an in- 
fected port. 

Kecokds, Reports, Etc. 

43. The officer making the inspection will preserve in his office a 
record of each inspection made and of each immunity certificate 
given; a copy of each certificate of disinfection and of each bill of 
health issued. 

A weekly report of the transactions of his office shall be for- 
warded to the Surgeon-General at Washington, D. C. 

44. In addition to the duties prescribed, the medical officer when 
detailed in accordance with the act of Congress approved February 
15, 1893, shall furnish such reports to the Surgeon-General of the 
Public Health and Marine-Hospital Service as he may be able to 
make upon sanitary conditions and other matters affecting the public 
health and the welfare of the Service administration. 

Requirements at Sea. 1 

45. The master of a vessel should observe the following measures 
or. board his vessel: — 

(a) The water-closets, forecastle, bilges, and similar portions of 
the vessel liable to harbor infection should be disinfected and fre- 
quently cleansed. 

(b) Free ventilation and rigorous cleanliness should be main- 
tained in all portions of the ship during the voyage and measures 
taken to destroy rats, mice, fleas, flies, roaches, mosquitoes, and other 
vermin. 

(c) A patient sick of a communicable disease should be isolated 



1 These requirements are largely advisory in character, but it is never- 
theless true that a careful compliance with them should tend, at the port 
of arrival, to largely relieve the stringency of quarantine measures. 



FOREIGN QUARANTINE. 485 

and one member of the crew detailed for his care and comfort, who, 
if practicable, should be immune to the disease. 

(d) Communication between the patient or his nurse and other 
persons on board should be reduced to a minimum. 

(e) Used clothing, body linen, and bedding of the patient and 
nurse should be immersed at once in boiling water or in a disinfect- 
ing solution. 

(/) The compartment from which the patient was removed 
should be disinfected and thoroughly cleansed. Articles liable to con- 
vey infection should remain in the compartments during the disin- 
fection when gaseous disinfection is used. 

(g) Any person suffering from malaria or yellow fever should 
be kept under mosquito bars and the apartment in which he is confined 
closely screened with mosquito netting. All mosquitoes on board 
should be destroyed by burning pyrethrum powder (Persian insect 
powder) or by fumigation with sulphur. Mosquito larvae (wigglers 
or wiggle-tails) should be destroyed in water-barrels, casks, and other 
collections of water about the vessel by the use of petroleum (kero- 
sene) ; where this is not practicable, use mosquito netting to prevent 
the exit of mosquitoes from such breeding-places. 

(h) In the case of plague, special measures must be taken to de- 
stroy rats, mice, fleas, flies, ants, and other vermin on board. 

(i) In the case of cholera, typhoid fever, or dysentery, the drink- 
ing water should be boiled and the food thoroughly cooked. The dis- 
charges from the patient should be immediately disinfected and 
thrown overboard. 

46. An inspection of the vessel, including the steerage, should be 
made by the ship's physician once each day. 

.47. Should cholera, yellow fever, small-pox, typhus fever, plague, 
or any other communicable disease appear on board ship while at 
sea, those who show symptoms of these diseases should be immediately 
isolated in a proper place; the ship's physician should then immedi- 
ately notify the captain, who should note same in his log, and all of 
the effects liable to convey infection which have been exposed to infec- 
tion should be destroyed or disinfected. 

48. The hospital should be disinfected as soon as it becomes 
vacant. 

49. The dead should be enveloped in a sheet saturated with one 
of the strong disinfecting solutions, without previous washing of the 
body, and at once buried at sea or placed in a coffin hermetically 
sealed. 



486 TEXT-BOOK OF HYGIENE. 

50. A complete clinical record should be kept by the ship's sur- 
geon of all cases of sickness on board, and the record delivered to the 
quarantine officer at the port of arrival. 

51. The following disinfecting solutions are recommended for use 
at sea : — 

Formulce for strong disinfecting solutions. 
Bichloride of Mercury. (1:500.) 

Bichloride of mercury 1 part 

Sea water 500 parts 

Mix. 

Carbolic Acid. (5 per cent.) 

Alcohol 50 parts 

Carbolic acid, pure 50 parts 

Mix. 

Then add fresh water 900 parts 

Formula! for weak solutions. 
Bichloride of Mercury. (1:1,000.) 

Bichloride of mercury 1 part 

Sea water 1000 parts 

Carbolic Acid. (2% per cent.) 

Carbolic acid, pure 25 parts 

Fresh water 1000 parts 

Formalin. (5 per cent.) 

Formalin (or formol) 50 parts 

Water 950 parts 

It is suggested that a vessel should carry for every 100 passengers : 
bichloride of mercury, 5 pounds; carbolic acid, 10 pounds; alcohol, 
10 pounds, and formalin, 10 pounds. 

EFFICIENCY OF FOREIGN REGULATIONS. 

The wisdom of this method of procedure and the efficient working 
of these regulations are demonstrated by the following statement 
taken from the report of the medical officer of the Marine-Hospital 
Service on duty at Naples, Italy, where, during the summer of 1893, 
cholera was epidemic: — 

"From the 15th of July to August 17th there were eight vessels 
cleared from Naples with steerage passengers — four for New York and 



FOREIGN QUARANTINE. 487 

four for South American ports. The first to leave was the Karamania, 
for New York, on July loth. No cholera at that time existed in 
Naples. The first case occurred in Naples on the night of the 16th, 
and the result of the bacteriological examination was not known until 
the afternoon of the 17th or morning of the 18th. 

"The passengers for the Karamania and the ship itself were put 
through the established routine. The ship was cleaned ; ventilation, 
etc., altered to conform with the United States law; closets and hos- 
pitals put in good order; water- and food- supply attended to; pas- 
sengers inspected and vaccinated, and both their baggage and clothing 
searched for food. Three days after sailing, i.e., on the 18th, a death 
from cholera occurred, and just before reaching New York there were 
two more. It is not unlikely that the infection in the first cases was 
traceable to the same source as those occurring in Naples on the 16th. 
It is more than probable that but for the careful exclusion of food 
brought by passengers there would have been more cases on the re- 
maining three ships for the United States. The regulations govern- 
ing infected ports were rigidly enforced. The first vessel to leave, four 
days after the cholera was announced, was the Massilia. Her passen- 
gers were met at the trains and conducted immediately on board; 
were there isolated three days, and all their baggage transferred across 
city unopened. All food was carefully looked into; all from persons 
or baggage excluded; and the baggage of a few, about whose ante- 
cedents there was doubt, disinfected by steam. The ship was warped 
out some distance from the pier every night, and an inspector kept on 
board night and day. There being no cholera known to exist anywhere 
in Italy outside of Naples, it was not thought necessary to disinfect 
all baggage or isolate for five days. She arrived safely in New York \ 
without mishap. The remaining two for the United States were the 
Weser and Cashmire; in both cases the regulations were enforced in 
detail. One lay about a mile and a half off shore during her five days. 
The other cruised at sea. In both cases an inspector was kept aboard 
day and night. Both escaped cholera. 

"The four for South America, with the result in each case, were 
as follows : The figures are not official, but are practically accurate in 
every respect. All were turned back by the South American author- 
ities: Vencinzio Florio — about 50 deaths; Andrea Dorio — 90 on 
way out, total not ascertained; El Remo — 84 deaths; Carlo R. — 
about 230 deaths. 

"To summarize, then, eight ships left Naples. The water-supply 
was the same and the food about the same; the class of passengers 



488 TEXT-BOOK OF HYGIENE. 

identical, and their places of origin similar — in many cases identical. 
All four leaving without precautions became floating pest-houses. Of 
the four for the United States the one leaving before cholera appeared 
in Naples had three deaths; the other three were made to conform 
to the regulations, and all escaped. In other words, every ship that 
left Naples had cholera except those in whose case the 'infected port' 
regulations were carried out; and of the five that had cholera, the 
only one that escaped with less than 50 deaths was the one on which 
our 'non-infected port' regulations were enforced, she having only 3 
deaths en route. In addition, the enforcement of the regulations 
compelled the abandonment of a number of other sailings for the 
United States. The escape of the Massilia, Cashmire, and Weser may 
be 'post/ not 'proper hoc/ but we certainly have the right to consider 
the evidence to be strongly on the side of 'propter/ " 

DOMESTIC QUARANTINE. 

The trans-oceanic part of the voyage completed, the vessel ar- 
rives in the waters of the United States, and here she is confronted by 
a municipal, State, or national quarantine station, where the ques- 
tion will be determined whether the measures prescribed have been 
carried out, whether they have been effective in the particular case, 
and, in fine, whether the vessel, her crew, passengers, and cargo, are 
or are not a menace to the health of the city and the country at large. 

MARITIME QUARANTINE STATIONS, 

In describing a maritime quarantine station it should be borne in 
mind that the details in the plant must vary in accordance with the 
special demands of each port. 

Thus, it is not to be expected that at Charleston, where immigra- 
tion is limited, there should be the same provisions for detention of 
immigrants as at New York, through whose portals more than one- 
third of a million of immigrants pass each year; or San Francisco, 
where enter the throng of travelers and immigrants from the far East. 

"We should not expect that Boston, in the more salubrious North, 
would have the means or adopt the practice of discharging ballast, 
cleaning and fumigating every vessel from an infected port, which 
is the invariable custom at Pensacola. 

But, leaving these variations for subsequent notice, the first 
thing to be considered, in the establishment of a complete mari- 
time quarantine, is proper location. This must be at a point remote 



DOMESTIC QUARANTINE. 489 

from city or village boundaries, and not likely to be encroached upon 
by urban growth. It should be more or less removed from the chan- 
nels of commerce, and yet be easily accessible. Indifference to proper 
location could very readily make the quarantine station a source of 
danger instead of a protection. 

THE QUARANTINE PLANT. 

The requirements of a maritime quarantine station may be enu- 
merated as follows: 1. A boarding-station. 2. A boarding-vessel. 
3. Anchorages. 4. Wharves with warehouse, disinfecting machinery, 
and machinery for discharge of ballast. 5. Lazaretto, or hospital for 
treatment of contagious diseases. 6. Hospital for treatment of non- 
contagious diseases. 7. Barracks for the detention, in groups, of sus- 
pects, or persons who have been exposed to contagion or infection. 
8. Bath-house. 9. Water-supply. 10. A cremation furnace. 11. 
Quarters for medical officers. 12. Laundry. 

1. The Boarding-station. — This includes a boat-house, with boat- 
men's quarters so located as to avoid infection from the Lazaretto, and 
to be within easy reach of passing commerce. 

2. Boarding-vessel. — The facilities for boarding and inspection 
will vary with the location of the station, whether within the limits 
of a land-locked harbor or exposed to the full force of wind and sea. 
In the former case a steam- or naphtha- launch, or even a row-boat, 
will suffice; but in the latter case the boarding-boat must be a 
steamer, preferably of the sea-going tug-boat type, for it must be 
remembered that any delay in making the inspection inflicts hard- 
ship on commerce, and must inevitably produce discontent and 
complaint. 

3. Anchorages. — Two anchorages, one for infected and one for 
non-infected vessels. The anchorage for the detention of the infected 
vessel should be conveniently removed from the main establishment 
and safely remote from the track of commerce. Its position should 
be sheltered, and good holding-ground for vessels' anchors is of the 
first importance. The channel to the anchorages, and, if necessary, 
their boundaries, should be plainly marked by buoys. 

4. Wharves. — A wharf or pier is a prime essential in the equip- 
ment of a complete station, and should be located in water at least 
twenty feet deep, and should be of such length that the largest ves- 
sels trading at the port can lie there safely; at least, in all ordin- 
ary weather. Upon this wharf there should be a warehouse for the 
storage of baggage and portions of cargo (practically, cargo is never 



490 TEXTBOOK OF HYCUENE. 

fully discharged, being disinfected in situ). On the wharf should be 
placed the steam disinfecting chambers, sulphur-furnaces, and tanks 
for holding disinfecting solutions. (At certain stations the disinfect- 
ing apparatus is necessarily placed on a barge.) "When required, a 
special, additional wharf should be provided for the discharge of 
ballast. 

Steam Disinfecting Chambers. — The principle of disinfection by 
steam was first advocated by Dr. A. • N. Bell, of Brooklyn; but the 
credit of first designing apparatus for the special purpose belongs 
to Dr. Joseph Holt, and his design was subsequently improved upon 
by Dr. Wilkinson and others. 

Steam Chambers. — These chambers consisted of cylindrical 
shells, made of strong boiler-iron, 40 to 50 feet long and 7 to 8 feet 
in diameter (inside measurement), furnished with doors at each end. 
The steam was admitted directly to the interior of the chamber, and 
in addition there was a coil of pipe for the application of dry heat. 
These chambers were fairly efficient in action, but there was a great 
waste of space, and with the exercise of every possible care there was 
always more or less wetting of fabrics by the water of condensation. 
Many improvements have been made from time to time in the con- 
struction of steam disinfecting chambers, those constructed for the 
national quarantine station at San Francisco, Cal., being of the same 
general construction, but dispensing with the coil of pipe, and substi- 
tuting therefor a jacket surrounding the entire chamber. 

The most recent steam chambers are of rectangular section, 16 
feet in length, 4 feet 6 inches in width, and 5 feet 6 inches in height, 
and are provided with steam-tight doors opening at either end. The 
chambers are constructed of an inner and outer steel shell 2% inches 
apart, with cast-iron end frames, intermediate truss bands, and of stay- 
bolt construction. 

The doors have concave steel plates riveted to cast angle frames 
fitted with heavy rubber gaskets; they are handled by convenient 
cranes, and drawn tight by drop-forged steel eye-bolts, swinging in 
and out of slots in the door-frames. The rectangular form is adopted 
in preference to the round, as it gives the most effective space during 
exposure, with little loss of steam, and enables cars on tracks to be 
readily handled in and out. The jacket is used to give perfect circula- 
tion and distribution of heat, to prevent condensation, and to dry the 
goods exposed. The jackets, which are filled with steam during the 
entire operation of the plant, make the chambers drying ovens; so 
that the articles to be disinfected are brought to the required tempera- 



DOMESTIC QUARANTINE. 491 

ture before the admission of steam to the inner chamber, and are 
thoroughly dried after the steam has been exhausted. 

In the experiments of Professor Koch in connection with Dr. 
Wollfhugel it was found that hot air alone, even at a temperature of 
230° to 248° F., after an exposure of three hours, would not with 
certainty destroy bacilli and spores. It is necessary, therefore, to 
eliminate the possibility of the pocketing of air, or of a mixture of air 
and steam, during exposure. To prevent this an inspirator is attached 
to the system of piping, whereby a vacuum of 10 to 15 inches is pro- 
duced in the chamber prior to the admission of steam. In previous 
chambers this important point was neglected, and this accounts for 
the unreliable results obtained by a number of disinfecting plants. 

For convenience of handling the goods to be disinfected, each 
chamber is provided with two cars of light wrought-iron construction, 
with removable trays with bottoms of galvanized-iron wire netting, 
and having a series of bronze wardrobe-hooks in the top of the frame- 
work, thus permitting the articles to be laid out upon the trays, or in 
the case of finer clothing, to be hung upon the hooks. The doors at 
both ends allow the cars to be brought in at one end and removed 
at the other, thus securing complete separation of infected and disin- 
fected articles. After exposure the cars, upon being unloaded, are 
returned to the working end of the chamber by means of transfer 
tables and side-tracks, permitting a continuous working of the plant. 

The system of piping is so arranged that steam may be admitted 
to the top or bottom of the chamber at will, through several openings, 
and has perfect circulation. Galvanized-iron hoods are placed in the 
chambers, so that steam is not forced directly on the clothing. The 
chamber is provided with thermometers to register the temperature, 
vacuum and steam-gauges, safety-valves, traps, and is covered with 
magnesia non-conducting covering. 

Sulphur-furnace. — For a long time the method of sulphur fumi- 
gation pursued was to put into iron pots a quantity of sulphur vary-, 
ing from three to four pounds to one thousand cubic feet, igniting this 
by means of alcohol, and to place them in the hold or apartment to 
be disinfected. An apparatus has been designed for the purpose of 
producing S0 2 in greater percentage, and consists of a furnace built 
on the reverberatory plan, with a series of shelves arranged one above 
another, each shelf carrying a pan of burning sulphur. A forced 
draught is kept up by means of a fan-blower connected at the bottom. 
The draught of air charged from the burning sulphur is made to 
reach and pass over the shelf above by means of apertures made by 



492 TEXT-BOOK OF HYGIENE. 

shortening the shelves alternately at their rear and front extremities. 
With an experimental furnace, Dr. Kinyoun states that "repeated 
experiments gave from 14 to 16 per cent, of S0 2 , temperature 21° 
C, while burning sulphur in a closed place gave only 6 per cent, 
at 21° C. — i.e., the air would not support the combustion of sulphur 
above that percentage." 

This has been almost entirely superseded by a furnace that is 
simpler in construction, and which has given admirable results in 
practice. The furnace is double, and has been provided with small 
fire-boxes at each end, over which are placed two shallow cast-iron 
pans five feet long, and the whole inclosed in a frame of sheet-iron. 
The sulphur is placed in the pans and a fire lighted in the furnaces, 
melting the sulphur, which quickly ignites. To prevent too rapid 
combustion baffle plates are arranged, and the proper quantity of air 
is admitted through adjustable valves in the furnace-fronts. The 
fumes of sulphur dioxide thus generated are collected and carried into 
a reservoir, from which they are sucked by an exhaust fan, and are 
thence forced through piping and large flexible hose to the apartment 
to be fumigated. 

The sulphur-furnace in use at the Louisiana Quarantine Station 
is the same in general principle, with the addition that the air sup- 
plied to the burning sulphur is aspirated from the hold of the vessel, 
and then forced into the furnace. 

Disinfection by Germicidal Solutions. — The apparatus for the 
use of the disinfecting solutions consist of a tank or tanks elevated 
above the level of the floor of the wharf to a sufficient height to force 
the solution through a hose and nozzle to the parts of the ship to be 
reached. The tank is to be filled by a steam-pump, and the solution 
is easily made by surmounting the tank with a keg perforated by 
numerous holes, in which keg the powdered bichloride is to be put, 
and the water for filling the tank pumped over it. 

It is a much better plan to have the bichloride solution distrib- 
uted by means of a special pump (made of iron to prevent amalgama- 
tion), as, with the pressure of the pump behind it, it penetrates much 
more deeply into cracks and crevices and, in fact, knocks the dirt and 
filth out of them. 

5 and 6. Hospitals. — The propriety of having separate hospitals 
for contagious and non-contagious diseases is so obvious that it need 
not be dwelt on here, and the necessity of a separate establishment 
for suspects, until the nature of their complaint can be positively 



DOMESTIC QUARANTINE. 493 

made out, is patent and only in accord with expediency and the ordi- 
nary instincts of humanity. 

7. Barracks. — Barracks for the detention of suspects are not 
an essential part of the equipment of every quarantine station, but 
are a necessity only at such stations as are situated at the great ports 
of entry, which are the ports of arrival of the vast hordes of immi- 
grants who seek our shores. Barracks are an indispensable adjunct 
in the management of ship-loads of immigrants suspected of being 
infected with cholera, typhus fever, and small-pox, and would be 
required in the case of yellow fever but for the fact that there is 
little or no immigration from the yellow-fever zone. 

The barracks should be commodious, substantial, and yet of sim- 
ple and inexpensive construction. They should be well ventilated 
and so arranged that every part of the building is under constant 
surveillance, and so subdivided that the inmates are divided into 
small groups and intercourse between the groups prevented. The 
immigration laws require that the immigrants shall be listed and ar- 
ranged in groups of thirty, and it would be well that this number 
be preserved as the unit for segregation. The barracks should be fur- 
nished with bunks, arranged in tiers one above the other, and fur- 
nished with bedding of a simple and inexpensive character. 

Clothing of a simple but sufficient kind, and capable of easy 
laundering, should be provided in sufficient quantity to furnish each 
inmate of the barracks witn a change while his or her own personal 
effects are undergoing the process of disinfection. Attached to the 
barracks there should be a kitchen, thoroughly equipped with all the 
facilities for furnishing hot food of a simple character for the num- 
ber of inmates provided for by the barracks. Dining-rooms should 
be arranged, and special care should be /taken to prevent the carrying 
of any food into the barracks. It is perhaps needless to say that, in 
the barracks, the sexes should be separated, and the better arrange- 
ment is to have two buildings— one for men and one for women and 
children. 

Latrines. — Latrines of ample size should be provided, and should 
be so arranged that all dejecta may be received into metallic vessels 
containing a germicidal solution of acknowledged potency; or, if the 
dejecta are to be received into a sewer, there should be some provision 
made for their complete disinfection prior to their discharge into the 
sea or a cess-pool. 

8. Bath-house. — Bathing facilities are an important part of the 
equipment of a quarantine station designed for the handling of large 



494 TEXT-BOOK OF BYGIENE. 

numbers of suspects. The best form of bath for the purpose is the 
shower- or rain-bath, it being more easily managed, more expeditious, 
and probably more efficacious than the tub-bath. The bath-house 
should be provided with a room for disrobing, from which the sus- 
pects will pass into the bathing-stalls proper, and there receive a bath 
the temperature of which is under the sole control of the bath- 
attendant. From the bath the suspect will pass into a robing-room, 
where he will be given a suit of sterile clothing, while the clothing 
which was removed in the disrobing-room is carried by proper attend- 
ants to the disinfecting apparatus, there to be rendered safe by ster- 
ilization. 

9. Water-supply. — An abundant supply of pure water is not only 
a desideratum, but a prime necessity, at all quarantine stations where 
it is designed to accommodate cholera suspects. It would be desir- 
able to provide a supply of twenty gallons per capita per day, and no 
arrangement will probably give such good results as the sinking of 
an artesian well, if the nature of the soil and the geological formation 
permit. If it is impracticable to sink such a well, the next best plan 
would be to arrange for the distillation or sterilization, by boiling, 
of a sufficient quantity of water for drinking purposes. 

10. Crematory. — A crematory is a desirable part of the equip- 
ment of every quarantine station, as it admits of no argument that 
cremation is the best possible method of disposing of the bodies of 
those dead of contagious or infectious disease. In addition, it would 
be desirable that all garbage and waste about a quarantine station be 
incinerated to prevent the possibility of infection. 

11 and 12. — Detailed description of quarters for medical officers 
and of laundry is unnecessary. 

Having thus considered the necessities and the desiderata in 
the equipment of a quarantine station, it is now proper to consider 
the regulations governing them, and for this purpose are here ap- 
pended the regulations prepared by the Supervising Surgeon-General 
of the Marine-Hospital Service, and promulgated by the Secretary of 
the Treasury on April 26, 1894. These regulations are to be con- 
sidered a minimum for the stations under municipal and State con- 
trol, some of which have additional requirements: — 



DOMESTIC QUARANTINE. 495 

Domestic Regulations. 

Quarantine Regulations to be Observed at Ports and on the Fron- 
tiers of the United States and its Possessions and Dependencies. 

Preamble. 

52. At or convenient to the principal ports, quarantine stations 
should be equipped with all appliances for the inspection and treat- 
ment of vessels, their passengers, crews, and cargoes. 

53. For all ports where such provisions have not been made, in- 
spection stations should be maintained. An inspection service should 
be maintained for every port throughout the year. 

54. At a fully equipped quarantine station there should be ade- 
quate provision for boarding and inspection, apparatus for mechan- 
ical cleansing of vessels, apparatus for disinfection by steam, by sul- 
phur, by formaldehyde, by disinfecting solutions, or any other method 
prescribed in these regulations; also a clinical laboratory, hospitals 
for contagious and doubtful cases, a steam laundry, detention bar- 
racks for suspects, bathing facilities, a crematory, a sufficient supply 
of good water, and a proper system for the disposal of sewage. 

55. The personnel of quarantine stations in the yellow-fever zone 
and on fruiters and other vessels of regular lines bound for southern 
ports from ports where yellow fever prevails should be immune to 
yellow fever. 

56. At quarantine stations all articles liable to convey infection 
should be handled only by the employees of said station unless the 
services of the crew of the vessel in quarantine are indispensable. 

57. Vessels having been treated at national quarantine stations 
that are located a considerable distance from the ports of entry of said 
vessels may be inspected by the local quarantine officer, and if for any 
sanitary reason it is considered inadvisable to admit the vessel, he 
should report the facts immediately by telegraph, when possible, to 
the Surgeon- General of the Public Health and Marine-Hospital Serv- 
ice, detaining the vessel pending his action. 

58. The following regulations are the required minimum stand- 
ard and do not prevent the addition of such other rules as, for special 
reasons, may be legally made by State or local authorities. 

Inspection. 

59. Every vessel subject to quarantine inspection, entering a 
port of the United States, its possessions or dependencies, shall be 



496 TEXT-BOOK OF HYGIENE. 

considered in quarantine until given free pratique. Such vessel shall 
tlv a yellow flag at the foremast head from sunrise to sunset, and shall 
observe all the other requirements of vessels actually quarantined. 

60. Vessels arriving at ports of the United States under the 
following conditions shall be inspected by a quarantine officer prior 
to entry: — 

(a) All vessels from foreign ports except those enumerated in 
paragraph 4. 

(b) Any vessel with sickness on board. 

(c) Vessels from domestic ports where cholera, plague, or yel- 
low fever prevails, or where small-pox or typhus fever prevails in 
epidemic form. 

(d) Vessels from ports suspected of infection with yellow fever, 
having entered a port north of the southern boundary of Maryland 
without disinfection, shall be subjected to a second inspection before 
entering any ports south of said latitude during the quarantine season 
of such port. 

61. The inspections of vessels required by these regulations shall 
be made between sunrise and sunset, except in case of vessels in dis- 
tress. 

62. In making the inspection of a vessel, the bill of health and 
clinical record of all cases treated during the voyage, crew and pas- 
sengers' lists and manifests, and when necessary, the ship's log shall 
be examined. The crew and passengers shall be mustered and exam- 
ined and compared with the lists and manifests and any discrepancies 
investigated. The clinical thermometer should be used in the exam- 
ination of the personnel of vessels under suspicion. When a freight 
manifest shows that rags and other articles requiring disinfection 
under these regulations are carried by the vessel, a certificate of dis- 
infection, signed by a United States consul or a medical officer of the 
United States, shall be exhibited and compared with same. If no 
certificate of disinfection is produced the collector of customs at the 
port of entry shall be notified of same by the quarantine officer. The 
collector of customs shall then hold such consignment in a designated 
place separate from other freight pending the arrival of the certificate 
of disinfection; and in the event of its nonarrival, the articles shall 
be disinfected as hereinbefore prescribed, or shall be returned by the 
common carrier conveying the same. 

63. The medical officers of the United States, duly clothed with 
authority to act as quarantine officers at any port or place within the 
United States, and when performing the said duties, are hereby au- 






DOMESTIC QUARANTINE. 497 

thorized to take declarations and administer oaths in matters per- 
taining to the administration of the quarantine laws and regulations 
of the United States. (Act of March 2, 1901, sec. 12.) 

64. No person, except the quarantine officer, his employees, 
United States customs officers, pilots, or other persons authorized by 
the quarantine officer, shall be permitted to board any vessel subject 
to quarantine inspection until after the vessel has been inspected by 
the quarantine officer and granted free pratique, and all such persons 
so boarding such vessel shall, in the discretion of the quarantine offi- 
cer, be subject to the same restrictions as the personnel of the vessel. 

65. TWboats or any other vessels having had communication 
with vessels subject to inspection shall themselves be subject to in- 
spection. 

6Q. After arrival at a quarantine station of a vessel carrying 
immigrants and upon which there has appeared during the last voy- 
age a case of cholera, small-pox, typhus fever, or plague, and after 
quarantine measures provided by regulations of the Treasury Depart- 
ment have been enforced and the vessel given free pratique, it is 
hereby ordered that notification of the above-mentioned facts be trans- 
mitted by the quarantine officer to the Commissioner of Immigration 
at the port of arrival, who shall be requested to transmit, by mail or 
telegraph, to the State health authorities of the several States to 
which immigrants from said vessel are destined, the date of departure, 
route, number of immigrants, and the point of destination in the 
respective States of the immigrants from said vessel, together with 
the statement that said immigrants are from a vessel which has been 
subject to quarantine by reason of infectious disease, naming the dis- 
ease. This information is furnished to State health officers for the 
purpose of enabling them to maintain such surveillance over the 
arriving immigrants as they may deem necessary. 

67. When a vessel arriving at quarantine has on board any of the 
communicable but non-quarantinable diseases, the quarantine officer 
shall promptly inform the local health authorities of the existence of 
such disease aboard and shall make every effort to furnish such notifi- 
cation in ample time, if possible, to permit of the case being seen by 
the local authorities before discharge from the vessel. 

Quarantine. 

68. Vessels arriving under the following conditions shall be 
placed in quarantine : — 



498 TEXT-BOOK OF J1YGTENE. 

(a) With qnarantinable disease on board or having had such 
disease on board during the voyage. 

(b) Any vessel which the quarantine officer considers infected. 

(c) If arriving at a port south of the southern boundary of 
Maryland in the season of close quarantine, May 1 to November 1, 
directly or via a northern port, from a tropical American port, unless 
said port is known to be free from yellow fever. 

(d) In the case of vessels arriving at a northern port without 
sickness on board from ports where yellow fever prevails, the per- 
sonnel shall be detained under observation at quarantine to complete 
five days from the port of departure. 

(e) Towboats and other vessels having had communication with 
vessels subject to quarantine shall themselves be quarantined if they 
have been exposed to infection. 

69. Vessels arriving under the following conditions need not be 
subject to quarantine: — 

A. Vessels from yellow fever ports bound for ports in the United 
States north of the southern boundary of Maryland, with good sani- 
tary condition and history, having had no sickness on board at ports 
of departure, enroute, or on arrival, provided they have been five days 
from last infected or suspected port. 

B. Vessels engaged in the fruit trade may be admitted to entry 
without detention, provided that they have complied in all respects 
with the special rules and regulations made by the Secretary of the 
Treasury with regard to vessels engaged in said trade. 



General Requirements at Quaran 

70. Pilots will be detained in quarantine a sufficient time to 
cover the period of incubation of the disease for which the vessel 
is quarantined, if, in the opinion of the quarantine officer, such pilots 
have been exposed to infection. The dunnage of pilots shall be dis- 
infected when necessary. 

71. No direct communication shall be allowed between any vessel 
in quarantine and any person or place outside, and no communication 
whatever between quarantine or any vessel in quaratine and any 
person or place outside except under the supervision of the quaran- 
tine officer. 

72. Street cleanings, street sweepings, or any other form of bal- 
last containing organic refuse must be discharged at the quarantine 
station. 



DOMESTIC QUARANTINE. 499 

73. No presumably infected ballast shall be allowed to leave the 
quarantine station until disinfected. 

74. After a vessel has been rendered free from infection, it may 
be furnished with a fresh crew and released from quarantine, while 
all or part of the personnel are detained. Under these circumstances 
the quarantine officer must exercise the greatest care that the vessel 
shall not become reinfected, especially by contact with persons in 
quarantine or infected objects. 

75. Vessels detained at any national quarantine will be subject 
to such additional rules and regulations as may be promulgated from 
time to time by the Surgeon- General. 

76. The form of certificate which shall be issued to a vessel by 
the health officer when he releases her from quarantine shall be pre- 
scribed by the Surgeon-General of the Public Health and Marine- 
Hospital Service, and shall embody the statement that the vessel has 
in all respects complied with the quarantine regulations prescribed 
by the Secretary of the Treasury, and that in the opinion of the 
quarantine officer she will not convey quarantinable disease, and that 
said vessel is granted free pratique to enter her port of destination, 
the name of which is to be embodied in the blank. 

77. The persons detained shall be inspected by the physician 
twice daily, and be under his constant surveillance, and no intercourse 
will be allowed between different groups while in quarantine. 

78. No articles from an infected vessel shall be carried into the 
place of detention until disinfected. 

79. Cleanliness of quarters and of person shall be enjoined and 
daily enforced. Disinfection shall be practiced where there is any 
possibility of infection. 

80. The water and food supply shall be strictly guarded to pre- 
vent any contamination. 

81. Water-closets, urinals, privies, or troughs shall be provided, 
and their contents disinfected before they are discharged. 

82. In any group in which communicable disease appears, the 
sick will be immediately isolated in hospital, and the remaining per- 
sons in the group and their effects appropriately treated and then 
removed to other quarters if possible, and the compartments disin- 
fected. 

83. Communication between the physician and attendants of the 
hospital and those detained in other parts of the quarantine station 
shall be reduced to a minimum. 

84. No convalescent shall be discharged from quarantine until 



500 TEXT-BOOK OF HYGIENE. 

after a sufficient time has elapsed to insure his freedom from infec- 
tion, and this is to be determined by bacteriological examination 
where possible. 

85. No other person shall be discharged from quarantine until 
the period of incubation of the disease has elapsed since the last 
exposure to infection. 

86. The body of no person dead of quarantinable disease shall 
be allowed to pass through quarantine until one year has elapsed since 
death. Such bodies must be transported in hermetically sealed cof- 
fins, the outsides of which have been carefully disinfected. 

In the case of the bodies of such persons as may have died on 
the voyage or upon arrival at quarantine, cremation should be re- 
sorted to if practicable and consented to; if not, the body should be 
wrapped without preliminary washing in a sheet saturated with a solu- 
tion of bichloride of mercury 1 :500 and buried, surrounded by caustic 
lime. 

87. The quarantine officer shall report to the Secretary of the 
Treasury all violations of the quarantine laws. He should also report 
the facts in the case to the Surgeon-General of the Public Health and 
Marine-Hospital Service. 

88. The quarantine officer shall report to the collector of cus- 
toms any vessel which arrives without the bill of health hereinbefore 
prescribed. 

89. All vessels requiring inspection under these regulations must 
present to the collector of customs at the port of entry the quaran- 
tine certificate above prescribed. 



Special Regulations on Account of Cholera. 

90. For the purpose of these regulations five days shall be con- 
sidered as the period of incubation of cholera. 

91. If the vessel carry persons from cholera-infected ports or 
places, a bacteriological examination should be made of any cases of 
diarrhea to exclude cholera before granting free pratique. 

92. If cholera has appeared on board, remove all passengers from 
the vessel and all of the crew, save those necessary to care for her; 
place the sick in hospital. Carefully isolate those especially suspected 
and segregate the remainder in small groups. No communication 
should be held between these groups. Those believed to be especially 
capable of conveying infection must not enter the place of detention 
until they are bathed and furnished with non-infected clothing; nor 






DOMESTIC QUARANTINE. $01 

shall any material capable of conveying infection be taken into the 
place of detention, especially food and water. 

93. Water and food supply must be strictly guarded to prevent 
contamination and issued to each group separately. 

94. Food of a simple character, sufficient in quantity, thoroughly 
cooked, shall be issued to those detained in quarantine. No fruit or 
uncooked vegetables shall be permitted. 

95. The greatest care must be exercised to prevent the spread 
of the infection through the agency of flies or other insects. 

96. The dejecta from all persons in quarantine on account of 
cholera shall be disinfected before final disposition. 

97. The water supply of the vessel, if suspected of infection, must 
be disinfected and then changed without delay; the casks or tanks 
disinfected and after thorough rinsing refilled from a source of un- 
doubted purity, or the water furnished must have been recently boiled. 

98. The baggage or effects of passengers and crew that may have 
been exposed to infection must be disinfected. 

99. Articles of cargo which have been exposed to infection and 
are liable to convey the same must be disinfected. 

100. Living apartments and their contents and such other por- 
tions of the vessel as have been exposed to infection must be dis- 
infected. 

101. Water ballast taken on at a cholera-infected port should 
be discharged at sea, or if discharged in fresh or brackish water must 
previously be disinfected. Vessels arriving with water ballast pre- 
sumably infected must return to sea under guard in order to dis- 
charge such ballast. If practicable the tanks should be disinfected 
before being flushed, and refilled with sea water. 

Special Regulations on Account of Yellow Fever. 

102. For the purpose of these regulations, five days shall be con- 
sidered as the period of incubation of yellow fever. 

103. Where practicable remove the sick to hospital; remove and 
isolate all persons not required for care of vessel. 

104. For the destruction of mosquitoes there shall be a prelimi- 
nary and simultaneous fumigation of all parts of the vessel by sul- 
phur dioxide gas. In cabins containing articles liable to damage by 
sulphur dioxide, pyrethrum powder may be burned instead. 

105. If, from the disposition of the cargo or any other reason, 
the previous fumigation is deemed not to have been effective, a com- 



502 TEXT-BOOK OF HYGIENE. 

pletc fumigation is now to be done, simultaneously, of the whole 
vessel. Measures are in all cases to be taken to destroy larvae of mos- 
quitoes aboard. 

106. The personnel of the vessel shall be detained five days from 
completion of disinfection, or if they have been removed before dis- 
infection of the vessel, their detention shall begin from last possible 
exposure to infection. 

If cases of yellow fever have occurred aboard, the time of deten- 
tion at stations south of the southern boundary of Maryland must be 
extended to six days. 2 

107. If the vessel has in all respects complied with the quaran- 
tine regulations to be observed at foreign ports in such cases, and has 
been disinfected under the supervision of an accredited medical officer 
of the United States at the port of departure, she may, upon arrival 
at her port of destination in the United States, with good sanitary 
history and in good condition, be subject to the following treat- 
ment : — 

(a) If arriving in five days or less, she may be admitted to 
pratique without disinfection or further detention than is necessary 
to complete the five days. 

(b) If arriving after five days and within ten days, she may be 
immediately fumigated and admitted without detention. 

(c) If arriving after a longer voyage than ten days, she shall be 
treated as if she had not been subjected to any previous treatment. 3 

108. Passenger traffic without detention may be allowed during 
the close quarantine season, May 1 to November 1, from ports in- 
fected with yellow fever to ports in the United States south of the 
southern boundary of Maryland under the following Conditions: — 

(a) Vessels to be of iron or the best class of wooden vessels, and 
to be cleaned immediately prior to taking on passengers. The officer 
issuing the bill of health to these vessels shall withhold the same if 
the vessel is not in first-class sanitary condition and complying in 
every respect with the conditions stated in this paragraph. 

(b) The vessel must lie at approved moorings in the open har- 
bor; must not approach the wharves, nor must the crew be allowed 
ashore at the port of departure. Every possible precaution must be 



2 The period of incubation of yellow fever is not rarely over five days. 

3 If the vessel should have been in transit for a considerable number of 
days, it is obvious that a case of yellow fever may have occurred and re- 
covered, leaving the vessel infected, and not affording any opportunity to the 
quarantine officer to determine same. 



DOMESTIC QUARANTINE. 503 

taken to prevent the ingress of mosquitoes, and to provide for the 
destruction of these should they find ingress. 

(c) All passengers and crew must be immune to yellow fever 
and so certified by the United States medical officer. 4 

109. The disinfection of baggage for yellow fever is not required, 
but baggage destined directly or indirectly for any State shall be dis- 
infected at the request of the health officer of said State. All bag- 
gage shall be inspected and the absence of mosquitoes definitely 
proven. The presence of any mosquitoes, regarding the infection of 
which the quarantine officer has doubts, shall be sufficient grounds 
for such further measures as the quarantine officer may deem justi- 
fiable. 

Special Regulations on Account of Small-pox. 

110. For the purpose of these regulations, fourteen days shall 
be considered as the period of incubation of small-pox. 

111. On all vessels arriving with small-pox on board, or having 
had small-pox on board during the voyage, any of the personnel who 
have been exposed to the infection of the disease must be vaccinated 
or detained in quarantine not less than fourteen days, unless they 
show satisfactory evidence of recent successful vaccination or of hav- 
ing had small-pox. 

112. Vessels arriving with small-pox on board which has been 
properly isolated and other sufficient precautions taken to prevent the 
spread of the disease need not be quarantined further than the re- 
moval of the sick, the disinfection of all compartments, baggage, and 
objects that have been exposed to the liability of infection, and such 
vaccination of the personnel as required in paragraph 111. 

113. On vessels arriving with small-pox on board and where the 
proper isolation and other precautions have not been taken, all those 
whom the quarantine officer believes to have been exposed to the 
infection will be detained unless they have had small-pox or unless 
they show satisfactory signs of having been properly vaccinated within 
one year. 

114. Living compartments and their contents or any other part 
of the vessel exposed to the infection must be disinfected. 

115. The baggage and effects of passengers and crew that have 
been exposed to the infection must be disinfected. 



4 The evidence of immunity which may be accepted by the sanitary 
inspector is: First, proof of previous attack of yellow fever; second, proof 
of continued residence in an endemic focus of yellow fever for ten years. 



504 TEXT-BOOK OF HYGIENE. 

Special Regulations on Account of Typhus Fever. 

116. For the purpose of these regulations twelve days shall be 
considered as the period of incubation of typhus fever. 

117. Vessels in otherwise good sanitary condition, but having 
typhus fever on board which has been properly isolated, need not be 
quarantined further than the removal of the sick, and disinfection 
of the compartments and their contents exposed to infection. 

118. If the case has not been isolated, or the disease has spread 
on board from person to person, the vessel will be quarantined, the 
sick removed, and those who have been exposed to the infection 
detained under observation. 

119. Vessels in bad sanitary condition, on which the disease has 
appeared, will be quarantined until thoroughly cleansed and disin- 
fected throughout ; the sick will be cared for at isolated hospitals, and 
those exposed to the infection detained under observation. 

120. The baggage and effects of passengers and crew that have 
been exposed to the infection must be disinfected. 

121. Living compartments and their contents, or any other parts 
of the vessel exposed to the infection, must be disinfected. 

Special Regulations on Account of Leprosy. 

122. Vessels arriving at quarantine with leprosy on board shall 
not be granted pratique until the leper with his or her baggage has 
been removed from the vessel to the quarantine station. 

123. No alien leper shall be landed. 

124. If the leper is an alien passenger and the vessel is from a 
foreign port, action will be taken as provided by the immigration laws 
and regulations of the United States. And to this end the case shall 
be certified as a leper and reported to the nearest commissioner of 
immigration. 

125. If the leper is an alien and a member of the crew and the 
vessel is from a foreign port, said leper shall be detained at the quar- 
antine at the vessel's expense until taken aboard by the same vessel 
when outward bound. Such case of leprosy should be promptly re- 
ported to the collector of customs at the port of arrival of the vessel, 
and the collector shall exact a bond from the vessel for the reship- 
ment of the said alien leper upon the departure of the vessel. 



DOMESTIC QUARANTINE. 505 

Special Regulations on Account of Plague. 

126. For the purpose of these regulations seven days shall be con- 
sidered as the period of incubation of plague. 

127. In those actually exposed to the infection of plague the 
administration of antipest serum is regarded as a valuable prophyl- 
actic measure; for the prevention of the introduction of plague into 
a community liable to the introduction of plague through commercial 
intercourse, immunization by Haffkine's prophylactic is to be rec- 
ommended. 

128. Vessels infected with plague, or suspected of such infec- 
tion, should be anchored at a sufficient distance from the shore or 
other vessels, to prevent the escape of rats by swimming. 

129. In inspecting vessels from plague-infected ports, or vessels 
with plague on board at port of departure, en route or on arrival, the 
personnel of the vessel should be examined with special reference to 
the glandular regions, cervical, axillary, and inguinal, and for such 
examination as much clothing should be removed as may interfere 
with the thoroughness of the process. When possible, females should 
be examined by female inspectors. 5 

130. In the inspection of vessels for plague, special attention 
must be directed to the discovery of cases of a mild type or of the 
pneumonic form of the disease. Suspected or doubtful cases should be 
subjected to bacteriological examination before the vessel is released. 

131. On all plague-infected vessels, any of the personnel of such 
vessels who, in the opinion of the quarantine officer, are infected or 
have been exposed to infection, shall be bathed and body clothing and 
hand baggage disinfected. 

132. Nothing shall be thrown overboard from the vessel, not even 
deck sweepings. Such material shall be burned in the furnaces of a 
steamer, or in a place specially designated, but not in the galley. 

133. Special precautions must be taken against rats, mice, ants, 
flies, fleas, and other animals, on account of the danger of the infec- 
tion of the disease being spread through their agency. 

134. As soon as practicable, there shall be a preliminary disin- 
fection with sulphur dioxide for the purpose of killing rats and ver- 
min, before further disinfecting processes are applied to the vessel 
and her cargo. The killing of any escaping rats shall be provided 



5 The examination herein provided being an exceedingly delicate matter, 
the greatest possible care is to be used by the quarantine officer to avoid any 
grounds for complaint of indecent exposure, and more particularly with 
regard to females. 



506 TEXT-BOOK OF HYGIENE. 

for by a water guard in small boats, and no person with abrasions or 
open sores should be employed in the handling of the vessel or her 
cargo. 

135. The vessel shall be submitted to a simultaneous disinfection 
in all parts with sulphur dioxide to insure the destruction of rats and 
vermin. The rats shall be subsequently gathered and burned, due 
precautions being taken not to touch them with the bare hands, and 
the places where found disinfected with a germicidal solution; and 
the quarantine officer shall assure himself that the vessel is free of 
rats and vermin before granting free pratique. 

136. Disinfection of vessels for plague shall be as follows: — 
With cargo : After twelve hours' exposure to sulphur dioxide, 

the upper 4 to 6 foot layer of cargo may be removed and placed on 
lighters exposed to the sun. This process of disinfection by night, 
and removal of successive layers of cargo by day, to be continued until 
hold is empty. 

137. Vessels without cargo shall be disinfected by sulphur diox- 
ide, followed by germicidal solutions, in accordance with the general 
regulations for disinfection, paragraphs 156 to 185. 

Canadian and Mexican Frontiers. 

138. When practicable, alien immigrants arriving at Canadian 
or Mexican ports, destined for the United States, shall be inspected 
at the Canadian or Mexican port of arrival by the United States 
consular or medical officer, and be subjected to the same sanitary 
restrictions as are called for by the rules and regulations governing 
United States ports. 

139. Inspection cards will be issued by the consular or United 
States medical officer at the Canadian or Mexican port of arrival to 
all such alien immigrants, and labels affixed to their baggage, as is 
required at foreign ports in the case of those coming direct to any 
port of the United States. 

140. If any person be found suffering from a quarantinable dis- 
ease, or be presumably infected, he shall be denied entry or shall be 
kept under quarantine observation so long as danger of conveying 
the infection exists. 

141. Any baggage or other effects believed to be infected shall 
be refused entry unless disinfected in accordance with these regula- 
tions. 

142. Persons coming from localities where cholera is prevailing 



DOMESTIC QUARANTINE. 507 

shall not be allowed entry until after five days have elapsed since last 
presumable exposure to infection, and their baggage disinfected. 

143. During the quarantine season persons not positively identi- 
fied as immune to yellow fever, coming from places where yellow fever 
prevails, will not be permitted to enter until they have been away 
from said localities five full days. 

144. Persons coming from localities where small-pox is prevail- 
ing shall not be allowed entry without vaccination, unless they are 
protected by a previous attack of the disease or a recent successful 
vaccination. The baggage of persons from such localities shall be 
disinfected. 

145. Persons coming from localities where typhus fever prevails 
in epidemic form shall not be allowed entry until twelve days have 
elapsed since their last possible exposure to infection and the disin- 
fection of their baggage. 

146. Persons coming from localities where plague is prevailing 
shall not be allowed entry until seven days have elapsed since their 
last possible exposure to infection and the disinfection of their bag- 
gage. 

147. No common carrier which is infected, or suspected of being 
infected, shall be allowed to enter the United States until after such 
measures have been taken as will render it safe. 

148. Articles of merchandise, personal effects, etc., which are 
presumably infected, shall not be allowed entry into the United States 
until after disinfection. 

149. Eags gathered and baled in Canada, accompanied by affi- 
davits that the ports or places where collected or handled were free 
from quarantinable disease for thirty days prior to shipment, may be 
admitted to entry ; but rags from foreign ports shipped through Can- 
ada shall not be admitted to entry unless they are accompanied by a 
certificate of a United States consul or medical officer of the United 
States that they have been disinfected, or until after they have been 
unbaled and disinfected at the port of arrival. 

150. Where not otherwise specifically stated, the rules and regu- 
lations for maritime quarantine shall be appMed at stations on the- 
Canadian and Mexican frontiers; and the methods of disinfection 
shall be those prescribed in these regulations. 

Special Regulations Relating to Naval Vessels. 

151. Vessels of the U. S. Navy may be granted the hereinafter 
stated exemptions from quarantine regulations, but are subject to 



508 TEXT-BOOK OF HYGIENE. 

quarantine inspection upon arrival at a port of the United States. 

152. The certificates of the medical officers of the U. S. Navy as 
to the sanitary history and condition of the vessel and its personnel 
may be accepted for naval vessels by the quarantine officer boarding 
the vessel in lieu of an actual inspection. 

153. Vessels of the U. S. Navy having entered the harbors of 
infected ports, but having held no communication which is liable to 
convey infection, may be exempted from the disinfection and deten- 
tion imposed on merchant vessels fom such ports. 

Inspection of State and Local Quarantine. 

154. In the performance of the duties imposed upon him by the 
act of February 15, 1893, the Surgeon-General of the Public Health 
and Marine-Hospital Service shall, from time to time, personally or 
through a duly detailed officer of the Public Health and Marine- 
Hospital Service, inspect the maritime quarantines of the United 
States, State and local, as well as national, for the purpose of ascer- 
taining whether the quarantine regulations prescribed by the Secre- 
tary of the Treasury have been or are being complied with. The 
Surgeon-General, or the officer detailed by him as inspector, shall, at 
his discretion, visit any incoming vessel or any vessel detained in 
quarantine, and all portions of the quarantine establishment, for the 
above-named purpose, and with a view to certifying, if need be, that 
the regulations have been or are being enforced. 

155. The Surgeon-General of the Public Health and Marine- 
Hospital Service is authorized, when in his discretion such action is 
necessary in the interest of the public health, to remand, by direction 
of the Secretary of the Treasury, any vessel to the nearest national, 
State, or local quarantine station provided with proper facilities for 
handling infected vessels. 

Disinfectants Authorized by these Begulations and the 
Proper Methods of Generating and Using Same. 

Physical Disinfectants. 

156. Burning. Of unquestioned efficiency, but seldom required. 

157. Boiling. Very efficient and of wide range of applicability. 
The articles must be wholly immersed for not less than thirty min- 
utes in water actually boiling (100° C). The addition of 1 per cent, 
of carbonate of soda renders the process applicable to polished steel, 
cutting instruments, or tools. 



DOMESTIC QUARANTINE. 50<J 

158. Steam: — . 

(a) Flowing steam (not under pressure). Flowing steam (not 
under pressure) when applied under suitable conditions is an efficient 
disinfecting agent. The exposure must be continued thirty minutes 
after the temperature has reached 100° C. 

(b) Steam under pressure without vacuum. Steam under pres- 
sure will sterilize, provided that the process is continued twenty min- 
utes after the pressure reaches 15 pounds per square inch. The air 
must be expelled from the apparatus at the beginning of the process. 
If impracticable to obtain the designated pressure, a longer exposure 
will accomplish the same result. 

(c) Steam under pressure with vacuum. Steam in a special 
apparatus with vacuum attachment is the best method of applying 
steam under pressure, the object of the vacuum apparatus being to 
expel the air and to promote the penetration of the steam. The 
process is to be continued for twenty minutes after the pressure 
reaches 10 pounds to the square inch. 

Gaseous Disinfectants. 

159. Sulphur dioxide. Sulphur dioxide is efficient, but requires 
the presence of moisture. It is only a surface disinfectant, and is 
lacking in penetrating properties. An atmosphere containing 4.5 
per cent, can be obtained by burning 5 pounds of sulphur per 1000 
cubic feet of space. This amount would require the evaporation or 
volatilization of about 1 pint of water. Under these conditions the 
time of exposure should be not less than twenty-four hours for bac- 
terial infections. A shorter time will suffice for fumigation necessary 
to kill mosquitoes and other vermin. 

160. The sulphur may be burned in shallow iron pots (Dutch 
ovens) containing not more than 30 pounds of sulphur for each pot, 
and the pots should stand in vessels of water. The sulphur pots 
should be elevated from the bottom of the compartment to be disin- 
fected in order to obtain the maximum possible percentage of com- 
bustion of sulphur. The sulphur should be in a state of fine division, 
and ignition is best accomplished by alcohol; special care to be taken 
with this method to prevent damage to cargo of vessel by fire; or 
the sulphur may be burned in a special furnace, the sulphur dioxide 
being distributed by a power fan. This method is peculiarly appli- 
cable to cargo vessels. 

161. Liquefied sulphur dioxide may be used for disinfection in 



;,10 TEXT-BOOK OF HYGIENE. 

place of sulphur dioxide generated as above, it being borne in mind 

that this process will require 2 pounds of the liquefied gas for each 
pound of sulphur as indicated in the above paragraphs. 

162. Sulphur dioxide is especially applicable to the holds of 
vessels, or to freight cars and apartments that may be tightly closed 
and which do not contain objects injured by the gas. Sulphur dioxide 
bleaches fabrics or material dyed with vegetable or aniline dyes. It 
destroys linen or cotton goods by rotting the fiber through the agency 
of the acids formed. It injures most metals. It is promptly destruc- 
tive to all forms of animal life. This property renders it a valuable 
agent for the extermination of rats, insects, and other vermin. 

Formaldehyde Gas. 

163. Formaldehyde gas is effective if applied by one of the 
methods given below. Formaldehyde gas has the advantage as n 
disinfectant that it does not injure fabrics or most colors. It is not 
poisonous to the higher forms of animal life. It fails to kill vermin 
such as rats, mice, roaches, bedbugs, etc. The method is not appli- 
cable to the holds of large vessels. Formaldehyde is applicable to 
the disinfection of rooms, clothing, and fabrics, but should not be 
depended upon for bedding, upholstered furniture, and the like, when 
deep penetration is required. 6 

164. Many formaldehyde solutions do not contain 40 per cent, 
of formaldehyde, and all are apt to deteriorate with time. It is there- 
fore necessary to use a quantity in excess of the amount prescribed 
in these regulations, unless the solution has been recently analyzed. 

165. The following methods of evolving the gas may be used : — 

(a) Autoclave under pressure, 3 to 12 hours' exposure. 

(b) Lamp or generator, 6 to 18 hours' exposure. 

(c) Spraying, 12 to 24 hours' exposure. 

(d) Formaldehyde and dry heat in partial vacuum, 1 hour's 
exposure. 

166. The minimum number of hours' exposure as given above 
applies to empty rooms of tight construction containing smooth, hard 
surfaces; the maximum number of hours' exposure applying in all 
cases to textiles and other articles of a similar kind requiring more 
or less penetration. 

167. Autoclave under pressure. This method has considerable 



6 It should be noted that formaldehyde disinfection is more efficient in 
warm, moist or still weather than in cold, dry or windy weather. 






DOMESTIC QUARANTINE. 511 

penetrating power when applied as detailed below. Rooms or apart- 
ments need no special preparation beyond the ordinary closing of 
doors and windows. Pasting, caulking, or chinking of ordinary cracks 
and crevices v is not necessary. The doors of lockers and closets and 
the drawers of bureaus should be opened. In this apparatus use for- 
malin (40 per cent.), with the addition of a neutral salt, such as 
calcium chloride (20 per cent.). The gas must be evolved under a 
pressure not less than 45 pounds. After the gas is separated from its 
watery solution the pressure may be allowed to fall and steam pro- 
jected into the compartment to supply the necessary moisture. Use 
not less than 10 ounces of formalin per 1000 cubic feet, and keep the 
room closed for three to twelve hours after the completion of the 
process. For large rooms the gas must be introduced at several 
points as far apart as possible. It is applicable to the disinfection 
of clothing and fabrics suspended loosely in such a manner that every 
article is freely accessible to the gas from all directions. 

168. Lamp or generator. This method requires an apparatus 
producing formaldehyde by a partial oxidation of wood alcohol, and 
in using it the room or apartment should be rendered tight as prac- 
ticable. Oxidize 24 ounces of wood alcohol per 1000 cubic feet, and 
keep the room closed for six to eighteen hours, in accordance with 
the provisions of paragraph 165. This method leaves little or no odor. 
When applied to clothing and textiles, the articles should be sus- 
pended in a tight room and so disposed as to permit free access of the 
gas. (See also Par. 166.) The wood alcohol should be of 95 per 
cent, strength, and should not contain more than 5 per cent, of ace- 
tone. 

169. Spraying. The formalin (40 per cent.) should be sprayed 
on sheets suspended in the room in such a manner that the solution 
remains in small drops on the sheet. Spray not less than 10 ounces 
of formalin (40 per cent.) for each 1000 cubic feet. Used in this 
way a sheet will hold about 5 ounces without dripping or the drops 
running together. The room must be very tightly sealed in disin- 
fecting with this process, and kept closed not less than twelve hours. 
The. method is limited to rooms or apartments not exceeding 2000 
cubic feet. The formalin may also be sprayed upon the walls, floors, 
and objects in the rooms. 

170. Formaldehyde with dry heat in partial vacuum. This 
method has superior penetrating powers and is specially applicable 
to clothing and baggage. The requirements of this method are (1) 
dry heat of 60° C. sustained for one hour; (2) a vacuum of 15 



512 TEXT-BOOK OF HYGIENE. 

inches; (3) formaldehyde evolved from a mixture of formalin with 
a neutral salt, in an autoclave under pressure, using not less than 
30 ounces of formalin (40 per cent.) for 1000 cubic feet; and (4) a 
total exposure, under these combined conditions, of one hour. 

171. The stated times of exposure to sulphur dioxide and for- 
maldehyde are sufficient to destroy bacterial infection due to non- 
spore-bearing organisms, providing that the infection is present on 
the surface. If the room is of peculiar construction, so as to impede 
the diffusion of the gas, or if the room is a dirty one, or if on account 
of any other condition rendering the germicidal action of the gas 
more difficult, the time of exposure should be proportionately in- 
creased, or supplanted by other methods. 

Chemical Solutions. 

172. Bichloride of mercury. Bichloride of mercury is a disin- 
fectant of undoubted potency and wide range of applicability. It 
cannot be depended upon to penetrate substances in the presence of 
albuminous matter. It should be used in solutions of 1 to 1000. The 
solubility of bichloride of mercury may be increased by using sea 
water for solution, or by adding 2 parts per 1000 of sodium or ammo- 
nium chloride to the water employed. 

173. Carbolic acid. Carbolic acid in the strength of 5 per cent, 
(see par. 51) may be substituted for the bichloride of mercury, and 
should be employed in the disinfection of the cabins and living apart- 
ments of ships to obviate injurious action on polished metals, bright 
work, etc. 

174. Formalin. Formalin containing 40 per cent, of formalde- 
hyde may be used in a 5-per cent, solution as a substitute for bichlo- 
ride of mercury or carbolic acid, and is useful for the disinfection of 
surfaces, dejecta, fabrics, and a great variety of objects, owing to its 
non-injurious character. 

Application of Disinfectants in Quarantine Work. 

175. Hold of iron vessel, empty, shall be disinfected by either: — 

(a) Sulphur dioxide generated by burning sulphur 5 pounds 
per 1000 cubic feet of air space, or liberated from 10 pounds of liquid 
sulphur dioxide, sufficient moisture being present in both cases; time 
of exposure, twenty-four hours. (See par. 159.) 

(b) Washing with a solution of bichloride of mercury, 1:1000. 

176. Holds of wooden vessels, empty, shall be disinfected by: — 



DOMESTIC QUARANTINE. 513 

(a) Sulphur dioxide in the manner prescribed above, followed by 

(b) Washing with a solution of bichloride of mercury. 

177. In the case of all vessels, both iron and wooden, when 
treated for yellow fever or plague infection, the first process shall be 
a preliminary fumigation by sulphur dioxide in the manner pre- 
viously stated in paragraph 159-160, in order to insure the destruc- 
tion of mosquitoes, rats, and other vermin. 

178. Holds of cargo vessels, when cargo cannot be removed, shall 
be disinfected in so far as possible by sulphur dioxide not less than 4 
per cent, per volume strength, and where possible this should be gen- 
erated from a furnace to minimize danger of fire in cargo. 

179. Living apartments, cabins, and forecastles of vessels shall 
be disinfected by one or more of the following methods : — 

(a) Sulphur dioxide, the destructive action of the gas on prop- 
erty being borne in mind. 

(b) Formaldehyde gas. 

(c) Washing with solution of bichloride of mercury, 1 :1000 or 
5-per-cent. solution of formalin, or 5-per-cent. solution of carbolic 
acid, preference being given to carbolic acid for application to pol- 
ished woods, bright metals, and other objects injured by metallic salts. 

The forecastle, steerage, and other living apartments in bad sani- 
tary condition must be disinfected by method (a) followed by method 
(c). 

180. Mattresses, pillows, and heavy fabrics are to be disinfected 

by-— 

(a) Boiling. 

(b) Flowing steam; i.e., steam not under pressure. 

(c) Steam under pressure. 

(d) Steam in a special apparatus with vacuum attachment. 

181. Clothing, fabrics, textiles, curtains, hangings, etc., may be 
treated by either of the above methods from (a) to (d) inclusive, as 
circumstances may demand, or by formaldehyde gas or sulphur dioxide 
where the article is of a character which will not be damaged by sul- 
phur dioxide. 

182. Articles injured by steam, such as leather, furs, skins, rubber, 
trunks, valises, hats and caps, bound books, silks, and fine woolens 
should not be disinfected by steam. Such articles should be disin- 
fected by formaldehyde gas or by any of the agents allowed in these 
regulations which may be applicable thereto. Those which will be 
injured by wetting should be disinfected by a gaseous agent. 

183. Clothing, textiles, and baggage, clean and in good condition, 

33 



514 TEXT-BOOK OF HYGIENE. 

but suspected of infection, can be efficiently and least injuriously dis- 
infected by formaldehyde gas, generated by one of the methods pre- 
scribed in paragraph 165 — (a), (b), or(d). 

184. Textiles which are soiled with the discharge of the sick or 
presumably are deeply infected, must be disinfected by: — 

(a) Boiling. 

(6) Steam. 

(c) Immersion in one of the germicidal solutions. 

185. Cooking and eating utensils are always to be disinfected by 
immersion in boiling water or by steam. 

It is the intention of the act of February 15, 1893, under which 
these regulations were framed, to have them act uniformly and with- 
out discrimination against any place, and at the same time to not 
interfere with the operation of any additional regulations imposed by 
State or local authority. 

MANAGEMENT OF A QUARANTINE STATION. 

Inspection. — Upon the arrival of a vessel at a quarantine station, 
during the active quarantine season, she should be boarded without 
delay, and the following general routine followed, with such modi- 
fications as may be demanded by the local conditions or dictated by 
the experience of the quarantine officer. In the event of the arrival 
of several vessels at the same time, they should, as a rule, be boarded 
as nearly as possible in the order of their arrival, the rule of "first 
come, first served" being observed; though it may be remarked that, 
in the event of the arrival, at nearly the same time, of a vessel carry- 
ing passengers and one carrying cargo only, there will usually be little 
opposition on the part of ship-masters if the passenger-ship is in- 
spected first. Arrived on board, it is well to demand the immediate 
attendance of the master, not only from the fact that all information 
must be sought from him, but to impress all concerned with the fact 
that the authority of the boarding-officer is, for the time, absolute. 
The master should then be required to produce for inspection his bills 
of health, the ship's manifest, and the crew- and passenger-lists, if the 
ship carry passengers. These should be carefully scrutinized, the 
number of crew and passengers being noted or borne in mind, and 
note being made of any articles of cargo that come within the pro- 
scription of the regulations. All special consular certificates bearing 
on doubtful articles of cargo had better be looked into at this time. 
A careful inspection of the ship should now follow, particular atten- 
tion being paid to the condition of the living-apartments of the 



TREATMENT OF YELLOW-FEVER VESSELS. 515 

officers and crew, as their condition of cleanliness or the reverse some- 
times forms an important index to the cleanliness of the whole ship. 
The hatches should be removed, and such portions of the cargo as 
come directly under them be subjected to scrutiny. If the vessel is 
in ballast, the hold should be entered, explored, and mental note made 
of the condition of the ship's inner planking or skin, whether dry and 
sound or rotten and damp. If possible, a limber plank should be 
lifted, and the condition of the bilges noted. In the comparatively 
inaccessible places fore and aft there will likely be found deposits of 
trash and filth, and the chain-lockers should be carefully examined 
to see whether the cables have been properly washed prior to stowing. 
The inspection of the ship proper completed, the inspection of per- 
sons should be entered into. 

Every person borne upon the ship's papers as passenger or mem- 
ber of the crew should be personally seen by the boarding-officer or 
his assistant, and no excuse whatever should be taken for an absence 
from this muster. In vessels suspected of the infection of plague or 
yellow fever, the temperature of passengers and crew should be taken 
to assist in the detection of cases of these diseases in the early stages, 
and to this end every quarantine station should be supplied with a 
liberal number of good clinical thermometers. Take nothing for 
granted, and compel the master to explain any discrepancies between 
the lists and the actual number presenting themselves for examina- 
tion. The decision must now be reached whether the vessel goes free 
under the regulations or is to be detained in quarantine. If the 
former, the certificate of inspection is filled out, and the master 
notified that he is at liberty to proceed. If the latter, the vessel is 
directed to a suitable anchorage, and the yellow quarantine flag is 
hoisted at the foremast-head. Quarantine procedures proper now 
begin, and much depends on the nature of the disease quarantined 
against; the nature and condition of the ship, whether light, in bal- 
last, or loaded. If there are passengers on board, these are landed, 
bathed, and assigned to quarters in the barracks. The vessel is laid 
alongside of the wharf and the disinfecting processes prescribed by 
the regulations entered upon. 

TREATMENT OF YELLOW=FEVER VESSELS. 

A vessel infected with yellow fever is one which has on board 
actual cases of the disease, or which contains mosquitoes of the genus 
Stegomyia fasciata which have had opportunities of biting persons 
infected with yellow fever, either at the port of departure or upon 



516 TEXT-BOOK OF HYGIENE. 

the voyage. If there are Stegomyia fasciata on board a ship and a 
case has occurred on board within three or four days, these mosquitoes 
must be regarded as infected, unless the utmost care has been taken 
to screen the patients from their attacks. If the ship is from a 
yellow-fever port, that is to say, where yellow fever actually prevails, 
and presents Stegomyia fasciata on board, these Stegomyiae are pre- 
sumably infected, and if as much as twelve days have elapsed on the 
voyage, are capable of conveying yellow fever to non-immunes. The 
treatment of yellow fever vessels, therefore, is limited to efforts 
directed to kill mosquitoes in the living apartments and in the holds 
of the vessel and to preventing their breeding in places favorable to 
their development. Various means can be adopted to this end. The 
burning of sulphur — two pounds per 1000 cubic feet, time of ex- 
posure twelve hours — is efficacious. If it is apprehended that the 
sulphur fumes will be injurious or prejudicial to clothing, hang- 
ings, bright work, polished metal, etc., pyrethrum powder may 
be substituted for the sulphur, burning one pound per 1000 cubic 
foot, the time of exposure to be about three hours. Pyrethrum pow- 
der is not an insecticide; it simply stupefies the insects, and at the 
expiration of this time the room or apartment should be cautiously 
opened and the stupefied mosquitoes swept up and burned. The use 
of pyrethrum, therefore, would generally be limited to the living 
apartments and especially to the cabins of ships; sulphur is safer, 
more efficacious, and easier of application in the forecastles and holds. 
Should there be patients sick with yellow fever upon the vessel 
on the arrival at quarantine, these should be at once removed to the 
infectious hospital if their condition permits it, and the remainder 
of the crew and passengers should be inspected twice daily until the 
time of danger, that is to say, the period of the incubation of the 
disease, five or six days, has elapsed. In the care and treatment of 
these passengers detained in quarantine on account of yellow fever, 
care should be taken to immediately isolate every febrile case and to 
thoroughly protect it by mosquito netting or wire gauze from the 
access of mosquitoes until a positive diagnosis is arrived at. If there 
are no mosquitoes, or care is taken to prevent the infection of mos- 
quitoes, there will be no spread of the disease. The ballast and cargo 
of vessels from yellow-fever ports are only dangerous in so far as 
they may harbor infected mosquitoes. The matter can be summed up 
in the dictum: "A vessel or a house infected with yellow fever is a 
vessel or house which contains within its walls infected mosquitoes 
of the genus Stegomyia fasciata." (Reed.) 



TREATMENT OF PLAGUE VESSELS. 51 7 

TREATMENT OF PLAGUE VESSELS. 

In vessels departing from a port where plague prevails, precau- 
tions against plague should be commenced at the port of departure. 
This disease has of late years been robbed of much of its traditional 
terror, owing to the fact that its cause, its nature, and the methods 
of handling it in epidemic form have become better understood. In 
the ordinary or bubonic type of the disease, there is little danger to 
be apprehended from the patient himself. In the cases pneumonic 
in type from their inception, or becoming pneumonic as a secondary 
infection, the patient is dangerous, as the sputum contains the organ- 
ism of the disease. 

The spread of plague seems to be generally effected by means 
of rats or mice, though insects, such as fleas, bedbugs, ants, etc., may 
also play a part, not by directly conveying the plague microorganism, 
but their bites, irritated by scratching, affording an avenue of entrance 
for the plague bacillus, which may be carried on the bodies or feet 
of the insects, or possibly conveyed in their dejecta. 

A most essential precaution in a port infected with plague is to 
prevent the access of rats, mice, and other vermin on board ship. This 
is best accomplished by not allowing the ship to approach the dock; 
but if this is necessary for the purpose of loading, the ship should be 
breasted off five or six feet from the walls of the dock, and the lines 
and chains leading ashore should be protected by rat-guards or cones 
surrounding the lines, their large open ends directed toward the 
shore. If these are impracticable, or not to be obtained, the lines 
or chains should be freshly tarred, and, as the rat is more prone to 
move by night than by day, the gang-ways or planks connecting the 
ship and the shore should be removed before sunset. 

A case of plague developing on the voyage should be isolated, and 
"any articles which may be soiled or infected by the patient should be 
disinfected or, in the absence of means for accomplishing this, should 
be destroyed. 

Careful observations should be made upon voyages from plague- 
infected ports to ascertain any marked sickness or increased mor- 
tality among the rats which almost always are found on shipboard. 
Experience has shown that an outbreak of plague in man is almost 
invariably preceded by an increased mortality among rats and mice. 

Arriving at a quarantine station, vessels infected with plague, 
or suspected of such infection, should be anchored at a sufficient dis- 
tance from the shore or from other vessels to prevent the escape of 



518 TEXT-BOOK OF HYGIENE. 

rats by swimming. The personnel of the vessel, passengers and crew, 
should be subjected to a rigid inspection, if there have been cases of 
plague during the voyage, and this inspection should be so conducted 
that the condition of the glandular regions of the body, the subcer- 
vical, axillary, and inguinal, may be ascertained. Special attention 
should be directed to the detection of mild or ambulant cases of the 
disease, and any case of illness partaking of the nature of a severe 
bronchitis or of pneumonia should be the subject of a special investi- 
gation and, if possible, a bacteriological examination. 

On plague-infected vessels, 'any of the crew who, in the opinion 
of the quarantine officer, have been exposed to the direct infection of 
plague should be bathed, and any of their belongings supposed to have 
been exposed to infection should be disinfected. Measures should be 
at once entered into to insure the destruction of rats, mice, fleas, bugs, 
and even flies and ants, on account of the danger of the spread of 
infection through their agency. This is best accomplished by a simul- 
taneous disinfection of the ship by sulphur dioxide. During this 
process, the escape of rats should be guarded against, and any rats 
found escaping should be killed by shooting or by means of sticks or 
other implements. The rats and mice killed by this fumigating 
process should be gathered, and it is best not to handle them with 
the naked hands. They should be collected with gloves and their 
bodies burned, and the spots upon which they have been found dead 
should be disinfected by actually boiling water or by one of the 
germicidal solutions, and the vessel should not be considered as free 
from danger until she is free from rats. The last International 
Sanitary Conference of Paris, 1903, lent themselves to the declaration 
that merchandise, in itself, was incapable of conveying the infection 
of plague, and was only dangerous when soiled or contaminated by 
plague-stricken rats. Should it be necessary to disinfect a ship in-, 
fected with plague and containing cargo, this disinfection should be 
conducted in a fractional manner, by removing a portion of the cargo 
and exposing it to sun and air upon lighters. Sulphur dioxide is 
then to be generated or introduced into the holds overnight, and dur- 
ing the next day a further portion of the cargo, not exceeding four to 
six feet in depth, should be removed. The holds are then closed again 
and the fumigation is repeated, and this process is continued until 
all cargo is removed. If the vessel contains no cargo, the holds should 
be disinfected by sulphur dioxide, dead rats sought for, gathered, re- 
moved, and burned, and a general disinfection by means of germicidal 



TREATMENT OF CHOLERA VESSELS. 519 

solutions should then follow. The water supply of a vessel plays no 
role in the dissemination of plague. 

If the vessel arriving with plague on board has a large number 
of passengers, these passengers should be removed, segregated into 
small groups, and held under observation for the period of the incu- 
bation of the disease, which is now considered as about seven days. 
Those who have been especially exposed to the infection should be 
segregated by themselves, and should form the subject of careful 
observation one or more times during the day. Any persons in these 
groups presenting suspicious symptoms of illness should be removed 
to the observation hospital; and if these cases should declare them- 
selves to be plague of either the bubonic or pneumonic type, they 
should be at once removed from the suspect to the infectious hospital. 

The International Sanitary Conference of Paris, 1903, recom- 
mended that all vessels engaging in passenger travel should be pro- 
vided with a sufficient quantity of anti-pest serum for the treatment 
of actual cases of plague and for the immunization of those exposed 
to its infection. This suggestion is well worthy of serious consid- 
eration, as the serum is an almost certain prophylactic and affords 
the only successful method known of treating actual cases of the 
malady. 

TREATMENT OF CHOLERA VESSELS. 

In the event of the arrival of a ship actually infected with 
Asiatic cholera, or suspected of such infection, a much more difficult 
problem confronts the quarantine officer, for the conditions differ 
widely from those obtaining in the case of the yellow-fever ship. In 
a majority of cases the cholera ship carries a large number of passen- 
gers, a great majority of whom belong to the immigrant class, and the 
difficulty of handling these is largely increased by the carelessness of 
their personal habits, their ignorance and disregard of the first laws 
of personal hygiene, and the discomfort, crowding," and bad sanitary 
condition of their quarters on board ship. Here many sources of 
danger must be looked into, and it is almost certain that a disregard 
of any one of them will be followed by a terrible retribution in the 
shape of new outbreaks of the disease. 

The first thing to be clone in the treatment of a cholera-infected 
ship is to remove her human freight, and this should be done as rap- 
idly as is consistent with safety. The occupants of the compartment 
of the ship in which cholera has appeared should receive our first and 
most careful attention. They must be landed at once, bathed with 



520 TEXT-BOOK OF HYGIENE. 

all possible precaution and thoroughness, furnished with clean, sterile 
clothing, and isolated in the barracks and regarded as especially dan- 
gerous. Those actually sick with the disease should be at once car- 
ried to the contagious hospital, and those sick with any complaint 
whatever isolated in the suspect hospital pending the determination 
of the actual nature of their disease. 

The foregoing applies particularly to the steerage passengers. 
The question of the treatment of the cabin and saloon passengers is 
one that will call for all the tact and ingenuity of the quarantine 
officer, and even then he will be liable to savage criticism and censure 
through the friends of the cabin passengers detained. It must be 
remembered that these passengers are luxuriously lodged and catered 
for with every delicate attention that ingenuity and long experience, 
sharpened by active competition, can suggest. On board ship they 
are most carefully guarded from intrusion on the part of the steerage 
passengers, and, in fact, are as nearly on a separate ship as possible. 
Is it always necessary to subject these people to the inconveniences 
and possible hardships that are inseparable from a detention in quar- 
antine barracks? The answer is that each case must be decided on 
its individual merits, and much will depend on the extent to which 
the ship seems infected, the seeming source of the infection, and the 
facilities which exist on board ship for maintaining a sharp line of 
demarkation between the steerage and saloon. 

If, on investigation, it seems that the choleraic outbreak is due 
to infected food smuggled on board by the emigrants, to infection 
probably brought aboard in the hand-baggage of the same class of 
passengers; if, in fine, it would seem to be due to conditions limited 
to the steerage, it might seem to be the part of wisdom to leave the 
cabin passengers in their luxurious quarters while the processes of 
disinfection and detention were in progress. If, on the contrary, the 
infection seems to be due to a polluted ship's water-supply; if there 
have been any cases of diarrhceal disease among the cabin passengers; 
if the infection seem to be distributed equally to the steerage and to 
the saloon, then all must be landed alike, and undergo barrack deten- 
tion, at least until the disinfection of the ship is thoroughly complete. 

The barracks for the cabin passengers must, of course, be of a 
different character from those provided for the steerage. They must 
be subdivided into small rooms, and, instead of hunks, must be fur- 
nished with comfortable cots, bedding, and simple, but neat and 
efficient, toilet facilities. A separate kitchen and table must be pro- 
vided for this class of passengers, and the whole situation may be 



SPECIAL MEASURES AGAINST CHOLERA. 521 

summed up by saying that the relative difference on shipboard should 
be preserved on shore during the detention in quarantine. 

SPECIAL MEASURES AGAINST CHOLERA. 

Other features of quarantine administration are well expressed 
in the following extract from the editorial pages of the Philadelphia 
Medical News of October 15, 1887, showing the measures necessary 
to extinguish an incipient epidemic of cholera and to prevent its 
spread. Such measures are as follow: — 

"(a) Speedy recognition and isolation of the sick; their proper 
treatment; absolute and rapid destruction of the infectious agent of 
the disease, not only in the dejecta and vomit, but also in clothing, 
bedding, and in or upon whatever else it finds a resting-place. 

"(b) The convalescents should remain isolated from the healthy 
as long as their stools possibly contain any of the infecting agent; 
before mingling again with the well they should be immersed in a 
disinfecting bath, and afterward be clothed from the skin outward 
with perfectly-clean vestments, which cannot possibly contain any of 
the infectious material. 

"(c) The dead should be well wrapped in cloth thoroughly* satu- 
rated in a solution of corrosive sublimate (1 to 500), and, without 
delay, cortege, or lengthy ceremonial, buried near the place of death in 
a deep grave, remote as possible from water which may, under any 
circumstances, be used for drinking, washing, culinary, or other domes- 
tic purposes. (Cremation, of course, is by far the safest way of dis- 
posing of cholera cadavers.) 

"(d) Those handling the sick or the dead should be careful to 
disinfect their hands and soiled clothing at once, and especially before 
touching articles of food, drinking, or culinary vessels. 

"(e) In the case of maritime quarantine, the well should be 
disembarked and placed under observation in quarters spacious enough 
to avoid crowding, and so well appointed and furnished that none will 
suffer real hardships. 

"(/) Once having reached the station, those under observation 
should be separated in groups of not more than twelve to twenty-four, 
and the various groups should, under no pretext, intermingle. The 
quarters for each group should afford stationary lavatories and water- 
closets in perfect working condition, adequate to the needs of the in- 
dividuals constituting the group, and supplied with proper means of 
disinfection. There should be a bed raised above the floor, proper 
coverings, and a chair for each member of the group, each person 



522 TEXT-BOOK OF HYGIENE. 

being required to use only his own bed. There should be a common 
table of sufficient size to seat around it all the members of the group, 
who should be served their meals from a central kitchen, and with 
table-furniture belonging to the station and cleaned by the common 
kitchen scullions. 

"(g) Drinking-water, free from possible contamination and of 
the best quality, should be distributed in the quarters of each group 
as it is needed, and in such a manner that it is received in drinking- 
cups only. There should be no water-buckets or other large vessels 
in which handkerchiefs, small vestments, children's diapers, etc., 
can be washed by the members of any group. 

"(h) Immediately after being separated into groups in their 
respective quarters, every person under observation should be obliged 
to strip and get into a bath (a disinfecting one is preferable), and 
afterward be clothed with fresh, clean vestments from the skin out- 
ward. Every article of clothing previously worn should be taken 
away and properly disinfected. 

"(i) Then all of the personal effects should be at once removed 
to a separate building, washed (if possible), and thoroughly disin- 
fected, or if necessary, destroyed. After disinfection they should be 
temporarily returned to the members of groups, when occasion re- 
quires a further change of clothing. 

"(Jc) Under no circumstances whatever should washing of cloth- 
ing by those under observation be permitted. All used clothing should 
be first thoroughly disinfected (by boiling, when possible), and then 
should be cleansed, the disinfection and washing being done by a 
sufficiently trained and absolutely reliable corps of employees supplied 
with adequate appliances. 

"(I) All those under observation should be mustered in their 
own quarters, and be subjected to a close medical inspection, while on 
their feet, at least twice every day, in order to discover and isolate, as 
soon as possible, new cases which may develop; and, of course, the 
clothing and bedding of these new cases should be treated without 
delay in the manner already mentioned. In the meantime, a watch 
should be set over the water-closets for the purpose of discovering 
cases of diarrhoea, and, when discovered, such cases should be tem- 
porarily separated from the rest. They should receive judicious 
medical attention at once, and precautions should be taken as if they 
were undoubted but mild cases of cholera. 

"(m) The quarters should be kept thoroughly clean, and every 
surface upon which infectious material could possibly be deposited, 



SPECIAL MEASURES AGAINST CHOLERA. 523 

including the floors, should be washed with a strong disinfectant 
twice daily, and oftener when necessary. Evacuations from the bowels 
should be passed into a strong disinfectant; the hopper of the closet 
should be then flushed and finally drenched with a quantity of the 
same disinfectant. 

"(n) For the proper attention to the sick, there should be two 
or more competent and experienced physicians, assisted by a sufficient 
corps of intelligent and efficient nurses, with hours of duty so arranged 
that a physician, with a sufficient number of nurses, shall be in con- 
stant attendance in the wards of the hospital. 

"(o) For the prompt recognition and separation of new cases, 
their temporary medical attention, the proper treatment of discovered 
cases of diarrhoea or cholerine and of other maladies, and the imme- 
diate correction of every insanitary practice or condition by constant, 
vigilant, and intelligent supervision, there should be at least two or 
more competent and experienced physicians, with hours of service so 
arranged that a physician is on duty night and day among those under 
observation; and he should have, subject to his orders at any and 
every moment, a sufficient and efficient corps of nurses and laborers 
to carry out properly and promptly his directions. 

"(p) In order to prevent the intermingling of the various groups, 
to enforce obedience and order, and to make it absolutely impossible 
for the quarantined and their personal effects to have any communi- 
cation with the exterior, a well-organized and sufficiently large police 
corps should patrol the borders of the stations and the buildings day 
and night. 

"(q) Any group among whom there have developed no new cases 
of cholera or of choleraic diarrhoea, during the preceding eight or ten 
clays, may be regarded as harmless, and allowed to leave quarantine 
after each one is finally immersed in a disinfecting bath and re- 
clothed with clean garments from the skin outward, the garments 
removed being destroyed or thoroughly disinfected and cleansed, as 
already indicated. 

"As yet no reference has been made to the crew, ship, and cargo. 
What has been said of the treatment of those under observation ap- 
plies to every one of the ship's inhabitants. The observation, isola- 
tion, and cleansing of the crew and their effects could safely be per- 
formed aboard ship if necessary. The ship should be thoroughly 
cleansed and disinfected, particular attention being given to the quar- 
ters of the emigrants and crew." 

The following general regulations were promulgated for the gov- 



524 TEXT-BOOK OF HYGIENE. 

eminent of camps and barracks for the detention of cholera suspects 
during the summer of 1892 : — 



*e 



Eegulations for Cholera Camp. 

(Prepared in the Marine-Hospital Bureau.) 

The surgeon in command of the quarantine camp to have abso- 
lute authority over the police and sanitary regulations of the camp, 
and to see that they are obeyed. 

Camp to be divided into two divisions — detention and hospital. 
Former for housing of suspected cases and well persons from infected 
localities and the latter for treatment of sick. 

Detention Camp. 

1. Persons destined for this camp to be assigned to specific 
quarters in tents. First to be subjected to disinfecting bath, and 
clothed afterward with fresh vestments. Not to leave this camp ex- 
cept by permission or order of surgeon in command. 

2. Persons in detention camp to be inspected twice daily or 
oftener by medical officer or assistant, while standing, to ascertain 
any new cases which may develop. 

3. New cases of cholera in detention camp to be immediately 
transferred to hospital camp for treatment, and all their effects dis- 
infected, as well as the tent in which they may occur. 

4. Guards to patrol detention camp night and day, to prevent 
intercourse between the two divisions of the camp. 

5. Water-supply for entire camp to be boiled for drinking. To 
be dealt out to each person in cups or glasses for potable purposes. 
May be acidulated with diluted hydrochloric acid under supervision 
of a medical officer. 

6. If there be room, the detention camp to be segregated into 
divisions of not more than twenty persons. ~No intercommunication 
should be permitted between the groups. 

7. All clothing removed from persons entering detention camp 
to be subjected to steam heat (unmixed with air), not less than 100° 
C. (212° F.), for one-half hour, or boiling for one hour. Leather 
and rubber goods to be immersed in 3-per-cent. carbolic-acid solution 
until thoroughly saturated. 

8. The washing of clothing not to be permitted by the detained 
persons under any pretext. After above disinfection, all laundry- 



SPECIAL MEASURES AGAINST CHOLERA. 525 

work to be then done by the force of employees. The clothing of 
detained suspects should be kept in separate building after disinfec- 
tion, and re-issued as required for change. 

9. Cleanliness and disinfection of quarters and person to be 
enjoined and enforced daily. Disinfectants to be used where there 
is any possibility of infection. 

10. At the expiration of five days, if no case of cholera or 
choleraic diarrhoea has developed in a given group segregated as above, 
those composing the group may be discharged, after a final disinfec- 
tion of person and clothing. 

11. All water-closets, urinals, privies, or troughs should be pro- 
vided with latrines similar to those of the cholera camp, and means 
should be provided for their thorough disinfection before their con- 
tents are discharged into pits of unslacked lime. 

12. Food issued shall be simple, thoroughly cooked, and served 
at stated hours. No fruit permitted. 

Hospital Camp. 

1. Day sick calls at 8 a.m. and 4 p.m. ; oftener, if necessary. 
Night call, 12 p.m., by night physician ; oftener, if circumstances 

require. 

2. There shall be one nurse for every hospital tent, who shall 
be on duty in six-hour watches. 

Night nurses according to circumstances. Female nurses for 
cases occurring in that sex. 

Nurses should be instructed in the necessity of personal hygiene 
and the sources of infection. 

3. Vomited matter and stools to be received into earthen vessels, 
and at once disinfected with 3-per-cent. solution of carbolic acid or 
1 to 500 HgCl 2 combined with 2 parts of HC1 to each part of HgCl 2 ; 
then thrown into a pit of unslacked lime, or discharged into the sea. 

4. All soiled linen or clothing that cannot be disinfected to be 
immediately destroyed by burning. 

5. When death occurs, body to be immediately buried, swathed 
in sheets saturated with 1 to 500 HgCl 2 . Place of interment to be 
selected to avoid contamination of water-supply. 

6. No persons having personal contact with the sick or dead shall 
leave the hospital camp without practicing disinfection, as specified 
above. 



526 TEXT-BOOK OF HYGIENE. 

DANGER FROM FLIES IN QUARANTINE. 

In this article it has been suggested that all dejecta and vom- 
ited matters of cholera patients be received into vessels containing 
an efficient germicidal solution; and this is not only for the reason 
that the said dejecta and vomited matters may infect any one who 
comes into inadvertent contact with them, but has an important bear- 
ing on the health of those who are resident in the neighborhood of 
the quarantine station. It has been abundantly proved that the ordi- 
nary house-fly is capable of conveying in its intestinal tract, for a 
considerable length of time, living and active cholera spirilla. Know- 
ing how constantly flies deposit their ordure on articles of food, it 
can easily be seen how great a menace to public health would be 
engendered by allowing stools containing the bacilli to remain with- 
out instant disinfection. The safer plan is, therefore, to not trust 
to subsequent disinfection, which might be overlooked in the press 
of other matters, but to receive the dejecta into the germicidal solu- 
lution so that no time will be lost and no chances of infection may 
remain. 

DANGER FROM MOSQUITOES IN QUARANTINE. 

As the consensus of opinion seems to be that the mosquito Stego- 
myia fasciata is the sole means for the dissemination of yellow fever, 
particular attention should be paid to guard patients in quarantine 
suffering from yellow fever from the attacks of this insect. Not only 
should the patient be carefully screened by mosquito nets, or by being 
kept in apartments rendered mosquito-proof by wire netting, but 
every effort made to prevent the breeding of this variety of mosquito 
in the neighborhood of a quarantine station. It is probable that this 
mosquito is a normal denizen of every quarantine station from the 
Eio Grande to the capes of Virginia, and measures for their preven- 
tion would consist in the thorough screening of all water-containers, 
water-barrels, or cisterns, and the filling in of all pools or collections 
of water which would form favorable places for their breeding and 
development. 

The Stegomyia fasciata is essentially a house mosquito and fresh 
water is necessary for its development. The collections of water 
which may ordinarily be found about a house, as in wash-bowls, wash- 
tubs, tin cans, broken bottles, etc., are particularly favorable places 
for its development, and these should be guarded against at a quar- 
antine station or in its immediate vicinity. 



THE NATIONAL QUARANTINE SERVICE. 527 

THE NATIONAL QUARANTINE SERVICE. 

The protection of the United States in the exclusion of quaran- 
tinable diseases is provided for at the forty national maritime inspec- 
tion and disinfection stations located in the waterways and f)orts of 
entry upon the Atlantic, Gulf and Pacific coasts. The principal sta- 
tions are as follows : — 

Perth Amboy, N. J.; Delaware Breakwater Quarantine Station, 
Lewes, Del. ; Reedy Island Quarantine Station, Delaware River ; Cape 
Charles Quarantine Station, Fisherman's Island, Va. ; South Atlantic 
Quarantine Station, Blackbeard Island, Sapelo Sound, Georgia; 
Brunswick Quarantine Station, Brunswick, Ga. ; Key West Quar- 
antine Station, Tortugas Islands, Fla.; Gulf Quarantine Station, 
Ship Island, Miss.; San Diego Quarantine Station, San Diego, Cali- 
fornia; San Francisco Quarantine Station, Angel Island, San Fran- 
cisco Bay, California; and Port Townsend Quarantine Station, Port 
Townsend, Washington; Southport, N. C; Savannah, Ga. ; Fer- 
nandina, Jacksonville, Miami, Key West, Punta-Gorda, Cedar Keys, 
Apalachicola, and Pensacola, Fla., and Astoria, Oregon. 

DESCRIPTION OF THE NATIONAL QUARANTINE STATIONS 
ON DELAWARE BAY AND RIVER. 

It may prove of interest to briefly describe a national quaran- 
tine station, and no better example can be found than the stations 
at Delaware Breakwater and at Reedy Island, Delaware River. These 
stations, while in a measure separate and distinct, are intended to 
work in connection with each other and to afford complete protec- 
tion against the importation of contagious and infectious disease 
through the medium of the commerce which seeks the port of Phila- 
delphia and the ports of entry on Delaware Bay, and situated in the 
States of Delaware, New Jersey, and Pennsylvania. At the station 
at Delaware Breakwater, which is situated at the mouth of Delaware 
Bay and immediately upon the point formed by Cape Henlopen, is 
the reservation, forty acres in extent, and surrounded by a substantial 
picket-fence ten feet in height. Within this enclosure is located the 
quarantine plant proper, consisting of commodious hospitals for con- 
tagious and non-contagious diseases, and barracks for the accommo- 
dation of one thousand suspects, fitted with bunks and provided with 
bedding and a full supply of clothing for both males and females. 
In connection with these barracks are a large kitchen, fully equipped 



528 TEXT-BOOK OF HYGIENE. 

with steam cooking-apparatus of the most improved description and 
a commodious mess-hall. There has been also provided a building 
containing a boiler for Operating the pumps, a bath-house, and laun- 
dry, which latter is equipped with appliances for washing all soiled 
clothing and for subjecting them to the boiling process. In this 
building there is also located a steam disinfecting chamber of the 
most modern and improved type, and adjoining this building is a 
bath-house fitted with twenty shower- and two tub-baths, all pro- 
vided with hot and cold water. An artesian well has been sunk, 
capable of supplying twenty thousand gallons of water per day, and 
this water is raised by a powerful pump to elevated tanks, and from 
these distributed to the barracks, kitchens, hospitals, laundry, and 
bath-house. 

Latrines are provided and furnished with iron containers hold- 
ing a strong disinfecting solution, and provision is made for empty- 
ing these containers into a sewer, which, in turn, empties into a sewer 
common to the bath-house and laundry, which discharges into the sea. 
The danger of soil contamination by alvine discharges is reduced to 
a minimum, and the water-supply likewise protected. Outside of the 
fence is a large brick house, which furnishes executive and admin- 
istrative offices and quarters for the medical officers on duty at the 
station. In front of the executive building is a lofty flag-staff, which 
affords the means for communicating by signals with vessels in quar- 
antine and arriving in the offing. 

Within a few hundred yards of the reservation is a long iron 
pier, which affords ample facilities for the landing of passengers. 

Situated fifty-five miles above the Breakwater, and forty-five 
miles from Philadelphia, is the Eeedy Island Quarantine Station, on 
and near the island of that name. Upon the island itself are situ- 
ated the residence of the medical officer, quarters for employees, and 
a cottage hospital. A boat-house is connected with the island by a 
gangway. The quarantine plant proper is located on a pier situated 
on the edge of the channel, and in thirty feet of water. The pier is 
two hundred feet in length, and presents a frontage of nearly four 
hundred feet, owing to the placing of an ice-break above and below the 
pier. This affords room for the accommodation of the largest vessels, 
and upon the wharf is situated the disinfecting plant, consisting of 
two steam chambers; a sulphur-furnace, fan and engine for driving 
the same; tanks for disinfecting solutions and a pump and hose for 
their distribution ; a fire-pump, and tanks for the storage of water 
for fire and steaming purposes. 



THE NATIONAL QUARANTINE SERVICE. 529 

There are only small barracks at this station, it being the plan 
that the vessel shall receive quarantine treatment at this point, and 
that the passengers shall undergo their detention in the barracks at 
the Breakwater station. 

Another national station which deserves special notice from its 
peculiarities is the quarantine vessel Jamestown, which can be con- 
sidered a floating quarantine station. The Jamestown was turned 
over to the U. S. Marine-Hospital Service by the Navy Department 
for quarantine use. She is one of the old-fashioned sailing-vessels of 
the navy, is very strongly and solidly constructed, and is one hundred 
and sixty-six feet long, thirty-six feet beam, and has a displacement 
of eight hundred and eighty-eight tons. She has been fitted for her 
present use by being housed in, and there have been placed on board 
a steam disinfecting chamber, a sulphur-furnace, tank for bichloride 
solution, and bath-rooms. In addition to these, she has been fitted 
as a place of detention for two hundred and fifty to three hundred 
immigrants, and is in all respects a complete quarantine station, and 
capable of doing valuable service in smooth water. 

AIDS TO NATIONAL QUARANTINE. 

In aid of the national quarantines, sanitary inspectors are ap- 
pointed by the Marine-Hospital Service at special points of danger, 
either in the United States or abroad. Through the State Depart- 
ment consular notification from foreign ports is received regularly by 
mail, or, in emergency, by cable, and the information thus received, 
and that received also from home ports, is ^communicated, by the 
Marine-Hospital Bureau, to all quarantine authorities, and others, by 
means of a weekly publication known as the "Public Health Keports." 

An important source of information concerning the movements 
of vessels in every portion of the world is the "Maritime Kegister," 
published in New York. The United States Collectors of Customs 
are efficient aids, having, by law, the power of search and detention 
of vessels, and having exceptional knowledge of the sanitary condi- 
tion of the shipping at their respective ports. The Eevenue-Cutter 
Service, a national coast patrol, gives frequent and efficient aid; the 
Light-house Establishment and Coast Survey render valuable assist- 
ance in locating and buoying the anchorages, and the Life-Saving 
Service, with its constant patrol of the coast, guards against the entry 
of a vessel at an unusual point. The surf-men are required to rake 
together and destroy dunnage and other material likely to be infected 
that have been thrown overboard and washed ashore from infected 

34 



530 TEXT-BOOK OF HYGIENE. 

vessels. Finally, the Marine-Hospital Service, having, besides the 
quarantines, the care of the sick of the merchant vessels of the United 
States, with one hundred and twenty-six physicians stationed at the 
larger and many of the smaller ports, is ready at a moment's notice 
to extend indefinitely its quarantine service. 

NATIONAL INSPECTION OF ALL QUARANTINES. 

The Act of Congress approved February 15, 1893, while con- 
templating that State and local quarantines shall not be disturbed 
in the exercise of their functions, provided said quarantines are ad- 
ministered in accordance with the law and the regulations made there- 
under, further provides that the rules and regulations of local quar- 
antines shall be examined by the Surgeon-General of the Marine- 
Hospital Service, and also that such additional rules and regulations 
as may be deemed necessary shall be made by the Secretary of the 
Treasury, and shall be enforced by the State or local quarantine au- 
thorities. If the latter refuse, or are unable to enforce them, the law 
further provides that the President of the United States shall detail 
or appoint an officer for this purpose. To carry out the intent of this 
law all the quarantines of the United States, national, State, and local, 
are inspected periodically by an officer of the Marine-Hospital Service. 
Following are the instructions prepared for the inspecting officers: — 

Instructions to Medical Officers of the Marine-Hospital 

Service Detailed to Make Inspections of 

State and Local Quarantines. 

Treasury Regulations. 

********* 

In the performance of the duties imposed upon him by the act 
of February 15, 1893, the Supervising Surgeon-General of the Marine- 
Hospital Service shall, from time to time, personally or through a 
duly-detailed officer of the Marine-Hospital Service, inspect the mari- 
time quarantines of the United States, State and local, as well as 
national, for the purpose of ascertaining whether the quarantine regu- 
lations prescribed by the Secretary of the Treasury have been, or are 
being, complied with. The Supervising Surgeon-General, or the 
officer detailed by him as inspector, shall, at his discretion, visit any 
incoming vessel, or any vessel detained in quarantine, and all por- 
tions of the quarantine establishment for the above-named purpose, 



NATIONAL INSPECTION OF ALL QUARANTINES. 53 1 

and with a view to certifying, if need be, that the regulations have 
been, or are being, enforced. — J. G. Carlisle, Secretary. 

General Instructions. 

A. Your inspections will include all ports within your district 
where vessels are allowed to enter and discharge cargo, and ports 
which may be used as ports of call. 

B. A separate report will be made of each station visited. 

C. Visit every part of the quarantine establishment, and take 
necessary precautions to prevent the conveyance of contagious or in- 
fectious disease through the medium of your own person. 

D. Visit the custom-house for the purpose of ascertaining whether 
the regulations with regard to bills of health and quarantine certifi- 
cates are being observed ; also, the immigration station for any perti- 
nent information. 

E. Eeports of a statistical character and descriptive of the quar- 
antine, called for herein, need be made but once in every six months, 
namely, on the date nearest the 1st of January and the date nearest 
the 1st of July; but any changes that have been made since the last 
general report should be immediately recorded. 

In making your report you will follow the special instructions in 
their order, referring to each by number, 

Special Instructions. 

1. Describe the quarantine station, location, buildings, anchor- 
ages, etc. Give limits of anchorage for non-infected and for infected 
vessels; facilities for inspection of vessels; apparatus for disinfec- 
tion of vessels and of baggage; facilities for removal and treatment 
of the sick, and for the removal and detention of suspects; mail and 
telegraph facilities, etc. 

2. Give personnel of the station or port ; name of the quarantine 
officer or officers; post-office address; total number of officers and 
subordinates, etc. 

3. Transmit copies of the laws under which the local quarantine 
is maintained, and copies of the quarantine regulations; also describe 
the quarantine customs of the port as they are carried out. 

Note. — There are sometimes slight, but possibly important, variations 
from the letter of the local regulations in the administration of quarantine. 
Also, local regulations generally allow a wide latitude to the quarantine 
officer, and how this latitude is used — i.e., how the quarantine officer inter- 
prets the spirit of the regulations — is very important. 



532 TEXT-BOOK OF HYGIENE. 

!. State what quarantine procedures, either under printed regu- 
lations or by custom, are enforced at the port, in addition to the 
requirements of the Treasury Department. 

It should also be stated whether there is undue or unnecessary 
detention or disinfection of vessels. 

5. State whether the inspection is maintained throughout the 
year or for what period, and what treatment of vessels is enforced 
during the entire year. 

6. Are vessels from other United States ports inspected? 

7. Describe quarantine procedures in the inspection of vessels, 
and, if infected, the treatment. Give time in quarantine (a) between 
arrival and commencement of disinfection, (b) time occupied by dis- 
infection, and (c) time after completion of disinfection of vessels until 
discharge. 

Xote. — Quick or slow handling of a vessel is of more importance com- 
mercially than the question of fees. The time lost is the vessel's heaviest 
expense, generally. 

8. "What communication is held with vessels in quarantine (and, 
before quarantine, by pilots, etc.), and how regulated? Is there any 
intercommunication allowed among vessels in quarantine? 

9. State what will be done with a vessel infected with cholera; 
second, a vessel infected with yellow fever; third, a vessel infected 
with small-pox (said vessels carrying or not carrying immigrants), 
and what conditions are regarded as giving evidence of the vessel's 
infection in each case. 

10. State whether records are kept, at the station, of the cases 
of disease that have occurred during the voyage, on arrival and during 
detention. 

11. Transmit schedule of quarantine fees, and give other fees and 
expenses necessarily and usually attendant on quarantine, as tonnage, 
ballast, wharfage charges, etc. 

12. Make a statement showing the number of vessels arriving at 
the port during the preceding calendar year, by months, (a) from 
foreign ports; (b) from foreign ports in yellow-fever latitudes via 
domestic ports; (c) from domestic ports. Show, also, the character 
of the commerce carried on by the port — i.e., from what countries 
chiefly the vessels come, and whether in cargo, ballast, or empty. 

13. State results of your visit to (a) the Custom-house; (b) the 
Immigration Bureau. 

14. State whether, in your opinion, the quarantine facilities are 
sufficient to care for the shipping entering the port. 



INLAND QUARANTINE. 533 

15. Name the quarantine regulations of the Treasury Depart- 
ment which are not properly enforced, and state specifically whether 
the regulations regarding inspection and disinfection, and particularly 
the period of observation after disinfection, of vessels are observed. 

16. Mention any facts which, in your opinion, should be known 

to the Department, bearing directly or indirectly upon the quarantine 

service, and make such recommendations as seem proper. — Walter 

Wyman, Surgeon-General. 

Note. — Report to be written on legal-cap paper (on one side only), 
signed, and inclosed in this blank as a cover. 

INLAND QUARANTINE. 

Under Inland Quarantine will be described The Sanitary Cordon, 
Camps of Probation, Railroad Quarantine, Disinfection Stations, and 
Inspection Service. 

THE SANITARY CORDON. 

This consists of a line of guards, military or civil, thrown around 
a district or locality, either to protect the same from the surrounding 
country when infected, or to protect the surrounding country from 
the infected district or locality. When a given locality is infected, and 
the adjacent territory is regarded as suspicious, it may be necessary to 
establish a double cordon, the first one embracing the whole suspected 
territory at its outer edge, the second investing more closely the well- 
defined infected locality. After the expiration of a sufficient time to 
prove that the area between the cordons is not infected, or has been 
.cleared of infection, the first cordon may be removed. Hospitals and 
camps of probation may be necessary adjuncts to the cordon. The 
most noted example of the sanitary cordon is found in the history 
of the plague-epidemic in Russia in 1878. A colony on the river 
Volga, called Wetljankaja, with a population of 1700 inhabitants, 
became infected with the Oriental plague, which extended to the 
neighboring villages. A military cordon was made to embrace all 
the infected district. The inhabitants of the focus of infection, 
Wetljankaja, were removed, property appraised for re-imbursement 
by the government, and the village burned. An additional cordon 
was thrown around Zarizin, a neighboring commercial city of impor- 
tance and terminus of the Russian railway system. The cordons were 
maintained several months, and the plague was stamped out. (See 
Abstract Sanitary Reports, vol. i [Bulletin's], page 78.) The sani- 



534 TEXT-BOOK OF HYGIENE. 

tary cordon is the customary method of preventing the spread of 
epidemic disease in the eastern countries. 

In the United States, when yellow fever prevailed in Pensacola, 
in 1882, to the extent of 2200 cases, the nav}^-yard reservation, whose 
boundary-line is within two miles of the city limit, and with a popu- 
lation of about 1500, was successfully guarded by means of a cordon 
and non-intercourse. 

The following year, 1883, the navy-yard itself was infected, and 
a cordon was thrown around it to protect the city of Pensacola, and 
was maintained for a period of sixty days. This cordon was under 
the management of the Surgeon-General of the Marine-Hospital 
Service, aid having been requested of the national government. The 
Collector of Customs of Pensacola was made the agent to execute the 
orders of the Marine-Hospital Bureau, and to the President of the 
local Board of Health was intrusted the immediate command of the 
line and guards. The cordon entirely surrounded the land-boundary 
of the naval reservation. Its line was four miles in length, one 
mile of it through a dense thicket, and was marked by blazed trees and 
flags. Forty men were employed as guards, an equal number being 
selected from each of the two political parties. Two captains were 
appointed, and were obliged to supervise the line night and day. 

The sentinel posts were furnished with tents, and two guards 
were allotted to each post, taking alternate watches of four hours 
each. A detention or probation camp was established and placed in 
charge of a physician, where persons wishing to leave the reservation 
were obliged to pass a .probationary period of twenty days. Xot more 
than half a dozen persons were received in this camp. Tjie govern- 
ment expended about $20,000 in these restrictive measures, which 
were entirely successful. Not one person got through the cordon line. 
The success was due largely to the thorough discipline maintained 
by the Collector and the President of the Board of Health. 

Yellow-fever Cordon in Texas. — In 1882, yellow fever prevail- 
ing in Mexico, along the Eio Grande, and in Brownsville, Texas, a 
sanitary cordon was established by the Surgeon- General of the Marine- 
Hospital Service, on request of the Governor of the State, extending 
along the line of the railroad from Corpus Christi, on the Gulf of 
Mexico, inland to Laredo, on the Eio Grande. This line was one 
hundred and eighty miles northeast of Brownsville, the triangular 
territory thus hemmed in by the cordon on one side, the Eio Grande 
on another, and the Gulf on the third, being all suspected territory, 
although the fever prevailed in only one corner of it — viz. : in Browns- 



INLAND QUARANTINE. 535 

ville. All persons were detained at least ten days at the cordon before 
being allowed to pass northward — a period of probation to insure that 
no one having the disease should carry it farther north. As soon as 
practicable another cordon was established much nearer to Browns- 
ville, only thirty miles from it, the line extending from the mouth 
of the Sol Colorado, on the Gulf of Mexico, to Santa Maria, on the 
Eio Grande. After a time sufficient to prove that no more fever 
prevailed between the two cordons, the first one was removed. Within 
the second line, where the fever prevailed, chiefly in Brownsville, a 
hospital was established and dispensaries opened for the gratuitous 
treatment of all applicants. 

Upon the Mexican side of the Eio Grande the fever continued 
to spread northwardly, and, in order to oppose it, still another cordon 
had to be established on the American side of the river, extending 
from Santa Maria on the south to Laredo on the north, a distance of 
five hundred miles. Three hundred guards, well mounted (Texan 
cow-boys), were employed in this cordon, and, while the disease was 
being stamped out in Brownsville, any further importation from 
Mexico was thus prevented. In Mexico the fever continued to spread 
until the authorities finally adopted measures similar to the above. 

The epidemic of yellow fever in Brunswick, Ga., in 1893, gave 
rise to the necessity of establishing a sanitary cordon to protect the 
surrounding country from the danger incident to the panic-engen- 
dered flight of the inhabitants of that town. On account of the 
peculiar situation of Brunswick the difficulties to be met were very 
great. Not only were numerous roads to be guarded, but three water- 
passages from the city into the surrounding country had also to be 
watched. The cordon, therefore, partook of the nature of both a land 
and water patrol, and the difficulties were successfully overcome, and 
no well-authenticated instances of escape through the lines were estab- 
lished. 

Much violent language has been used concerning the hardships 
imposed by the sanitary cordon, but in the presence of an epidemic 
the authorities who are responsible need to pay more heed to the 
efficiency of the cordon than to individual complaints. It should be 
borne in mind that the sanitary cordon is not intended to bottle up 
all the people who are caught within an infected district. On the 
contrary, it is intended as a means of exit to those who will not carry 
with them contagious disease to the people beyond. 

The cordon, then, imposes simply a period of detention corre- 
sponding to the incubative period of the prevailing disease. Ample 



536 TEXT-BOOK OF HYGIENE. 

preparation must be made for housing and feeding, in camps or other 
quarters, persons awaiting the expiration of the detention period ; and 
hospitals must be provided for the treatment of those who develop 
sickness. Provision must also be made for the disinfection of sus- 
pected baggage. 

CAMPS OF PROBATION. 

Camps of probation or detention should be established with all 
the precision of arrangement and regard for site, water, and drainage 
that pertain to a military camp. Every effort should be made to make 
the camp as comfortable and cheerful as possible, and to this latter 
end amusements and entertainments such as might be suggested by 
the campers themselves should be encouraged. Every necessity in 
the matter of food, bedding, and the ordinary comforts of life should 
be anticipated, to prevent any just cause of complaint. Such a nat- 
ural division of the inhabitants should be made as seems desirable at 
the time, those of equal intelligence and refinement naturally seeking 
each other's company. The greatest concern is to prevent the camp 
itself from becoming infected. To this end no baggage should be 
allowed within the camp-boundary without previous examination or 
fumigation, to ensure its freedom from mosquitoes ; and every refugee 
should be examined by a physician before being admitted to the camp. 
Xo one should be received who does not intend to proceed to an un- 
infected locality after his probation. In other words, a camp of 
probation should not be used as one of refuge. 

The camp must be surrounded by guards to prevent egress or 
ingress, excepting through the established portal. At least twice or 
three times in the twenty-four hours all refugees should be inspected 
in their quarters, and any case of sickness at once be isolated and 
watched and screened from mosquitoes until the diagnosis is certain. 
If the case is one of the prevailing disease, the patient must be re- 
moved immediately to the hospital, which should be at a safe distance, 
half a mile or more, from the camp. Before leaving the camp, cloth- 
ing should be fumigated to destroy mosquitoes, and he should be given 
a certificate that he has passed the required period of probation. A 
clear distinction must be made between camps of probation and camps 
of refuge. Camps of refuge are simply residence camps established to 
receive the population of an infected community, when it has been 
determined to depopulate the infected district. 

Depopulation of a house, a block, a district, or a whole city, if 
possible, the people moving into camps, is now recognized as a valu- 



INLAND QUARANTINE. 537 

able means of controlling an epidemic ; and there may be either camps 
of probation or simply camps of refuge, or both, according to the 
requirements of the situation. Camps of refuge, in connection with 
depopulation, were suggested by the late Surgeon-General Woodworth, 
in 1878, and the measure was practically carried out at Memphis, in 
1879, by the establishment of Camp Mitchell. "But the establish- 
ment of a camp to which persons from infected points could go, be 
kept under observation a sufficient length of time to demonstrate they 
were not infected, have their baggage disinfected, and be given 'free 
pratique/ is apparently a new departure in inland quarantine." 

Camp Perry, Fla. — Such was Camp Perry, Florida, described by 
the surgeon in charge, W. H. H. Hutton, in the Marine-Hospital 
Service Eeport for 1889. The site was admirably chosen by Passed 
Assistant Surgeon John Guiteras, upon a bluff on the south side of 
St. Mary's Kiver, the dividing line between Florida and Georgia, about 
forty miles north of Jacksonville, Fla., which city was in the throes 
of a yellow-fever epidemic. The camp was opened August 20, 1888. 
It consisted, in its completed stage, first, of 50 wooden cottages built 
elsewhere and transported on cars. Their dimensions were 12 feet 
by 10, and 10 feet in height, constructed of plain lumber, with cracks 
battened, and windows on each side with swinging shutters. Each 
held four cots, chairs, and toilet-stand, while unused clothing was 
neatly arranged on the rafters above. Besides the 50 cottages there 
were a quartermaster and guard-house, commissary building, dining- 
room and kitchen, and laundry, built of rough lumber; 2 Ducker 
portable barracks, each 18 by 35 feet, provided with 12 beds each, and 
350 tents, used principally by the single men, the employees and 
guards, and the colored refugees. So far as known, this is the first 
camp of the kind ever established ; at least, in the United States. The 
cottages were arranged in a quadrangle around a parade-ground two 
acres in extent, and the tents were arranged in streets and alleys in 
the rear of the cottages. The accommodations were sufficient for 
600 people, and extra tents were on hand so that, if required, 1000 
persons could have been provided for, or 3000 per month, allowing 
for only ten days' detention of each person. Two hundred hospital 
tents will accommodate 1200 people comfortably, according to Sur- 
geon Hutton, who states that the small A-tents are unsuited for 
women and children, but will answer for men or boys. Wire-mattress 
cots should be provided. The Marine-Hospital officer at Savannah, 
Ga., was the purchasing agent for the camp, and promptly forwarded 
all subsistence supplies on requisition by mail or telegraph. 



538 TEXT-BOOK OF HYGIENE. 

Discipline of the Camp. — On arrival of a train, each passenger 
was personally examined by a physician, his health-certificate scruti- 
nized, and he was made to await the examination of others. Hand- 
bags, clothing, and loose wearing-apparel were left in the baggage-car 
for disinfection. The refugees were then conducted to the quarter- 
master's room for registration and assignment to quarters. On first 
arrival they were placed in the southern part of the camp, and in two 
days, there being no sickness, were moved forward several cabins, and 
this progression was repeated until the time for discharge. 

Twelve guards were employed, under the command of a captain, 
and were divided into squads of four each. The schedule was so 
arranged that each guard was on duty two hours and off duty four. 

A bugler announced the several calls, as follow: — 

5.30 a.m Reveille. 

6.00 a.m Breakfast, employes. 

7.00 a.m Breakfast, guests. 

9.00 a.m Surgeon's call and inspection. 

12.00 M Dinner, employes. 

1.20 p.m Dinner, guests. 

4.30 p.m Surgeon's call and inspection. 

5.30 p.m Supper, guests. 

6.00 p.m Supper, employes. 

6.30 p.m Retreat and change of guard. 

9.00 p.m Retiring taps. 

The yellow-fever hospital camp, under the special charge of Dr. 
Faget, was located one-half mile from the probation camp. It con- 
sisted of 2 frame buildings, 2 hospital and 12 smaller tents, arranged 
in a double-crescent shape, the avenue in the middle presenting an 
attractive appearance. 

Of the 12 small tents, 4 were for nurses, 3 for employees, 2 for 
convalescents, and 1 each for drug-store, storage- and dead-house. 
One of the hospital tents was used as a dining-room for employees, 
convalescents, and parents of the sick. 

The hospital was established September 3, 1888, and between 
that date and November 24th 35 cases of yellow fever were admitted 
and treated, 3 died, and 32 were discharged. Twelve hundred and 
eleven refugees were received into Camp Perry, nearly all of whom 
were from the infected district of Jacksonvir.e. 

Thirty-five cases of yellow fever were caught by the ten days' 
detention, but no case of fever was contracted at the camp, and of 
the 1208 refugees who passed the required detention and proceeded 
to different parts of the country, so far as known, not one subsequently 



INLAND QUARANTINE. 539 

developed or carried the disease elsewhere. The general plan of the 
preventive measures adopted during this epidemic will be described 
under Eailroad Quarantine. 

Detention Camp, Waynesville, Ga. — The epidemic of yellow fever 
in Brunswick, Ga., in 1893, caused the establishment of another camp 
of probation near Waynesville, Ga. Following is the report of the 
medical officer in command : — 

"Sir: I have the honor to present the following report of the 
operations of the detention camp near Waynesville, Ga. 

"The camp was officially opened for the reception of refugees 
from Brunswick, Ga., on the 18th of September, 1893, and closed by 
the order of Surgeon, E. D. Murray, Marine-Hospital Service, per- 
mitting the return of all refugees to their homes in Brunswick, No- 
vember % 30, 1893. 

"Four hundred and thirty-one persons availed themselves of the 
privileges of the camp, of whom about two hundred and twenty-five 
were white and the remainder black and colored. 

"The site of the camp was selected by Surgeon W. H. H. Hutton, 
and was twenty-three miles west of Brunswick, immediately upon and 
on the south side of the Brunswick and Western Eailway, and upon 
an eminence about twenty-five feet above the level of the surrounding 
country, which is generally swampy, and within a mile of the margin 
of what is locally known as the Buffalo Swamp. As is usual in this 
section, the elevation was covered with a dense growth of yellow-pine, 
scrub-oak, and black-gum trees. The soil was a gray, sandy loam, 
overlying a stratum of yellow clay, and the natural drainage of the 
site in all directions was good. 

"On my arrival I found that, under the direction of Surgeon 
Hutton, an area of two hundred feet had been cleared of trees and 
undergrowth, and at the four corners of this square rough but sub- 
stantial buildings had been erected, which were used, respectively, as 
kitchen, white and colored dining-rooms, guard-room, quartermaster's 
store-room, executive office, telegraph office, and commissary. A depot 
and baggage-room were provided at the railway. Along the lines con- 
necting these buildings, at intervals of twelve feet, were placed wall- 
tents, twelve by fourteen feet, with flies, and subsequently further 
row r s of tents were pitched behind these and opening on streets four- 
teen feet wide. All tents were provided with substantial floors raised 
six inches above the ground, and the following equipment was pro- 
vided: For each inmate, one spring, wire-bottomed cot, one cotton 
mattress, one hair pillow, two sheets, one pillow-case, and, for each 



4Q TEXT-BOOK OF HYGIENE. 



tent, two tin wash-bowls, two tin cups, and two wooden chairs. Re- 
markable ingenuity was displayed by the inmates in the construction 
of articles of furniture from packing-cases, waste lumber, etc. The 
tents proved of good quality in service, and quite comfortable in all 
weather. It is suggested, however, that any future tents be constructed 
with a wall two feet higher and of one foot greater pitch. A hospital 
establishment of two buildings was provided at a distance of one-half 
mile from the camp. A lofty pine-tree was fitted with a topmast, and 
served as a staff for the display of the national colors from sunrise 
to sunset each day. 

"The following routine was observed, the calls being given by the 
bugle : — 

5.30 a.m Reveille and attendants' breakfast. 

6.00 a.m Breakfast. 

8.00 a.m Sick call. 

12.00 m Dinner. 

4.00 p.m Sick call. 

5.00 p.m Supper. 

Sunset Retreat and call to quarters. 

9.00 p.m Tattoo. 

9.15 p.m Taps (extinguish lights) . 

"The meals were substantial, abundant, and as varied as possible. 
In all cases women and children were served at the first table, and the 
races were served in separate dining-rooms. 

"The following rules were announced, and seemed to work well 
in practice: — 

"1. At reveille all inmates will rise and prepare for breakfast. 

"2. All quarters must be clean, floors swept, and beds made up 
before first sick call. 

"3. Meals will be served in the dining-rooms only, and at stated 
hours, and no meals shall be carried from the dining-rooms to any 
quarters, except upon the written order of the medical officer, renewed 
from day to day. 

"4. At sick calls all inmates will repair to their quarters, and be 
there visited and inspected by the medical officer, who will prescribe 
or advise as he may deem best. 

"5. All suspicious cases of disease will be isolated at once, and 
until such time as the nature of the same may be determined. 

"6. All cases of infectious disease will be treated only in the hos- 
pital provided for the purpose. 

"7. No baggage from infected localities shall be brought into 
camp until disinfected by such process as may be directed, and only 



INLAND QUARANTINE. 541 

such wearing-apparel as may be deemed absolutely necessary will be 
brought into camp after the disinfecting process. 

"8. All wearing-apparel shall be a second time disinfected before 
discharge from camp. 

"9. Any person taken ill between two sick calls shall at once 
notify the nearest guard, who will, in turn, at once notify the medical 
officer. 

"10. Guards are enjoined by their vigilance to prevent the com- 
mission of any nuisance near any quarters; should such nuisance be 
discovered, the inmates of the nearest quarters will be required to 
police the same under the supervision of the guard, who will make 
report of the same. 

"11. Inmates will confine themselves to the inner lines of the 
camp after retreat (sunset) call. 

"12. While innocent enjoyment will be encouraged, the strictest 
propriety of conduct will be demanded and enforced. 

"The discipline of the camp was, in the main, good throughout. 
But two confinements for misbehavior were required during the entire 
duration of the camp. 

"All baggage was submitted to steam disinfection upon arrival 
at and departure from camp. The apparatus used was devised by 
Surgeon H. E. Carter, Marine-Hospital Service, and was constructed 
in a baggage-car, the steam being supplied by a locomotive. 

"In addition to other duties, nearly sixteen hundred cars, boxes, 
and flats were disinfected for the B. and W. Eailway, sulphur fumi- 
gation being used for the boxes and drenching with acid solution of 
bichloride of mercury (1 to 800) for flat cars. This disinfection of 
cars enabled the traffic into Brunswick to be carried on with a mini- 
mum of delay and hardship. 

"Two cases of yellow fever occurred among the inmates of the 
camp, one resulting in recovery, one in death. Both cases occurred 
in the persons of sailors who had arrived in Brunswick on vessels 
trading there, and both would seem to show a period of incubation 
of at least five days, thus justifying our detention of ten days." 



THE INFLUENCE OF THE MOSQUITO UPON THE MANAGEMENT 
OF YELLOW FEVER. 

Such was formerly the routine of the management of detention 
and probation camps. With the advance of definite knowledge on 
the subject of the etiology and methods of conveying yellow fever, 



542 TEXT-BOOK OF HYGIENE. 

this would be modified in certain particulars where the camp is in- 
tended for the prevention of the spread of yellow fever. The disin- 
fection of baggage from the place infected with yellow fever would 
no longer be required further than to insure the destruction of mos- 
quitoes that might be contained therein; and the methods for the 
prevention of yellow fever within the camp from cases arising in 
inmates after entry would be limited to screening them from the 
access of mosquitoes and to the elimination of places and conditions 
favorable to the multiplication of the Stegomyia fasciata. 



THE MANAGEMENT OF EPIDEMICS OF YELLOW FEVER IN 

THE LIGHT OF THE MOSQUITO TRANSMISSION 

OF THE DISEASE. 

As may be well imagined, the promulgation of the mosquito doc- 
trine of the transmission of yellow fever, and its general acceptance 
by scientists and sanitarians, has necessitated some radical departures 
in the handling of epidemics of yellow fever. Whereas it was for- 
merly considered that fomites were the principal agent in the dis- 
semination of the infection, it is now generally recognized that these 
articles play absolutely no role in the transmission of the disease, and 
that measures for the suppression of an epidemic must be based upon 
the destruction of the mosquito of the genus Stegomyia fasciata and 
the shielding of actual cases of yellow fever from the attacks of these 
insects. It seems to be accepted that if there are no mosquitoes of 
this genus, or if such mosquitoes are not allowed to bite individuals 
sick with yellow fever, there will be no spreading of the disease. 

The following extracts from publications of the Public Health 
and Marine-Hospital Service show clearly the basis upon which 
restrictive epidemic measures are founded, and the report of the 
management of the epidemic of yellow fever in Laredo, Texas, and 
at various points along the Texas-Mexican border in 1903, give a 
clear idea of the practical application of measures founded upon this 
doctrine. 

Far from making the work of the sanitarian more easy, this doc- 
trine has necessitated more rigorous care even than was formerly 
necessary, and it is easy to see that a failure to recognize cases early, 
to screen them from the bites of mosquitoes, or to destroy mosquitoes 
and the places favorable for their breeding, will be followed by disas- 
trous results in the shape of a spread of the epidemic. Cases of yellow 
fever plus the existence of mosquitoes of the genus Stegomyia fasciata 



INLAND QUARANTINE. 543 

will always mean more cases of the disease. Absolute shielding of 
cases of the disease from the attacks of mosquitoes, and the destruc- 
tion of the breeding places of such mosquitoes, will result in a dis- 
appearance of the epidemic. In fact, were all febrile cases of what- 
ever nature protected from the attacks of the insects, and were mos- 
quitoes not allowed to propagate by careful and rigorous attention to 
the accepted methods for their destruction, there need be no spread 
of the disease; but a failure in any minute particular to follow out 
these two principles would render any efforts for the suppression of 
the epidemic largely negatory. 

It is notoriously a matter of difficulty to recognize cases of yellow 
fever in a city or locality where the disease has not recently pre- 
vailed in epidemic form, and therefore too much stress cannot be laid 
upon the necessity of screening all febrile cases until a positive diag- 
nosis can be made. This applies equally to the conveyance of malarial 
fevers by mosquitoes of the genus Anopheles, as to yellow fever by the 
Stegomyia. Not only is the mosquito dangerous to the public health, 
but the malarial or yellow fever patient is prejudicial to the Ano- 
pheles or Stegomyia by infecting it prior to rendering it a vehicle for 
the transmission of infection. The infection of yellow fever is only 
contained in the blood of the yellow-fever patient during the first 
three or four days of the malady, and by this time the nature of the 
illness can usually be determined. 



THE CAMPAIGN OF PROPHYLAXIS AGAINST YELLOW FEVER 
ON THE TEXAS=MEXICAN BORDER, 1903=04. 

The epidemic of 1903 having ended, it became necessary, in view 
of sanitary and climatic conditions, to inaugurate a vigorous cam- 
paign of prophylaxis along the Texas-Mexican border and in all 
places in Texas where the disease had prevailed during 1903, to guard 
against a recrudescence of the fever in the spring of 1904. 

"A sanitary inspection of the territory situated in the triangles 
between San Antonio, Laredo, Corpus Christi, and Brownsville was 
inaugurated and officers detailed to investigate the conditions along 
the lines of railway travel to detect any possible recrudescence of the 
disease. A campaign of instruction, showing the methods of drain- 
age, destruction of mosquitoes, oiling of water-containers, etc., and 
the screening of all yellow fever patients, was carried out, supple- 
mented with aid in fumigation of premises, etc., where requested, and 
no doubt the generally satisfactory condition of affairs at this time 



544 



TEXT-BOOK OF HYGIENE. 



(September 30, 1904) is due to this early anticipatory sanitary cam- 
paign in aid of the State and local authorities. 

"In addition to the measures already enumerated, it was con- 
sidered advisable as a precautionary measure to prepare, pack, and 
store small camp outfits at five points upon the Louisiana-Texas 
border, thereby saving time in shipment should an emergency arise. 
These camp outfits were accordingly stored at the selected points." 

It is pertinent to add that the measures were entirely successful, 
no yellow fever making its appearance in Texas during the summer of 
1904. 

RAILROAD QUARANTINE AND INSPECTION SERVICE. 

Railroad quarantine and inspection service may be described by 
a brief account of the actual measures of this nature made use of 
during the yellow-fever epidemic in Florida, in 1888, of which Camp 
Perry, just described, was an important adjunct. (For details, see 
annual reports Marine-Hospital Service, 1888 and 1889.) 

The Governor of Florida made application to the national au- 
thorities, July 16th, for aid, and it was determined to prevent further 
spread of the disease by disinfecting all baggage from infected locali- 
ties before permitting its transportation into other States, and by 
enforcing, upon all persons from infected localities seeking to leave 
the State, a probationary detention of ten da} T s. 

Accordingly, disinfection stations were established at two points, 
through which all persons leaving Florida by rail were obliged to pass. 
One of these was at Live Oak, in Northwestern Florida; the other at 
Way Cross, Georgia, near the boundary-line of Northeastern Florida. 
The only other means of egress from the State was from the sea- 
ports ; but healthy sea-ports maintained a vigorous quarantine against 
people from the infected districts, and infected sea-ports were not 
visited by the steam-ship lines, because their vessels would thereby 
be made liable to quarantine detention at other ports. The fumiga- 
tion of baggage at Live Oak and Way Cross was accomplished by 
means of box-cars specially prepared, and subsequently in warehouses, 
the agent being sulphur dioxide. 

Regarding persons, the inspectors, properly uniformed and wear- 
ing official shields, boarded the trains when the latter arrived at the 
inspection stations, and demanded of each passenger a certificate, 
showing where he had been during the previous ten days, which cer- 
tificate was considered valid only when it bore the seal or signature of 
some officer of health, or recognized municipal authority. The in- 



INLAND QUARANTINE. 545 

spectors themselves were kept informed regarding all infected or sus- 
pected localities, and a person coming from such locality was either 
made to return to it or given the option of going to the camp of pro- 
bation, there to spend the ten days' period of probation before being 
allowed to enter other States. 

This was Camp Perry, previously described, located 38 miles 
south of the Way Cross Station, and 40 miles north of Jacksonville, 
where the epidemic prevailed chiefly. All egress from Jacksonville 
was, perforce, through Camp Perry and its ten days' probation. 

This camp was a means of protecting not only other States, but 
the uninfected portions of Florida itself, more particularly Southern 
Florida, whose health authorities refused to admit within their limits 
the refugees from the infected districts unless they had passed the 
period of probation at Camp Perry. To assist in this protection to 
Southern Florida, no person was' allowed to board a south-bound 
train between Way Cross, on the north, and Orange Park, a station 
20 miles south of Jacksonville. 

Moreover, through south-bound trains were boarded at Way Cross, 
and all passengers compelled to furnish evidence of coming from 
healthful localities. The evidence consisted of certificates from local 
authorities, baggage-checks, or railroad-tickets showing they were pur- 
chased in the North, and in some instances letters showing by the 
superscription and stamps where the person had been. 

No train, excepting the special government train, was allowed to 
stop at Camp Perry. A government train also carried those who had 
passed the period of probation from Camp Perry to a point 3% miles 
distant, Fo'kstone, where they were transferred to a regular train 
running as far north as Way Cross, Ga., where another transfer had 
to be made to a regular north-bound train. No Florida passenger- 
car was allowed to go north, and more than 1000 baggage- and freight- 
cars were disinfected by government officers before being allowed to 
leave the State. 

Train-inspection Service during the Brunswick Epidemic. — Dur- 
ing the Brunswick epidemic the following regulations for the inspec- 
tion of trains were promulgated and enforced: — 

"Inspectors will allow none to board a train, unless with a cer- 
tificate, between Way Cross and Savannah. 

"If certificate can be examined before boarding, without deten- 
tion to train, it must be done, and those which are unsatisfactory will 
not be allowed to board. 

"After boarding, the certificate and the person must be carefully 



546 TEXT-BOOK OF HYGIENE. 

examined and the inspector assure himself that the passenger is not 
recently from Jesup or any infected locality. 

"If the passenger is known to he a recent resident of Jesup or 
any infected locality, or to have been in such place during the past 
two (2) weeks, he will not be allowed to board, even if he has a cer- 
tificate. 

"If, after boarding, either the certificate or the examination of 
passengers is not satisfactorjr, the passenger will be turned over to 
the city authorities at Way Cross or Savannah, or at the place where 
he desires to stop. , If between these places, the facts to be noted and 
reported. 

"A record will be kept of the names of all passengers inspected, 
name of signer of certificate and his rank, date of inspection, date of 
certificate, and place of boarding train ; and where passenger is bound 
and what disposition is made of him, whether passed or turned over 
to local authorities; also any other facts worth notice. 

"Inspectors will aid local quarantine authorities in any way in 
their power consistent with their duties, and give them any informa- 
tion, obeying all local quarantine regulations. Inspectors report to 
Surgeon Carter, United States Marine-Hospital Service, or A. P. 
English, M.D." 

The methods of railroad quarantine may also be studied in a 
review of the action taken to prevent the introduction of small-pox 
into the United States from Canada, where it prevailed extensively in 
the fall and winter of 1885, and January and February, 1886. 

The following regulations were issued by the Surgeon-General of 
the Marine-Hospital Service, October 10, 1885 : — 

"The act approved April 29, 1878, entitled "An act to prevent 
the introduction of contagious or infectious diseases into the United 
States," provides that no vessel or vehicle coming from any foreign 
port or country where any contagious or infectious disease exists, or 
any vessel or vehicle conveying persons, merchandise, or animals 
affected with any contagious disease, shall enter any port of the United 
States, or pass the boundary-line between the United States and any 
foreign country, except in such manner as may be prescribed under 
said act. 

"Attention is now directed to the prevalence of the contagious 
and infectious disease of small-pox in Montreal and other places in the 
Dominion of Canada, and the law referred to is held to apply alike 
to trains of cars and other vehicles crossing the border, and to vessels 
entering ports on the northern frontier. 



INLAND QUARANTINE. 547 

"Because, therefore, of the danger which attaches to the trans- 
portation of persons and baggage, and articles of merchandise, or ani- 
mals, from the infected districts, the following regulations are framed, 
under the direction of the Secretary of the Treasury, and subject to 
the approval of the President, for the protection of the health of the 
people of the United States against the danger referred to : — 

"1. Until further orders all vessels arriving from ports in Canada, 
and trains 'of cars and other vehicles crossing the border-line, must 
be examined by a medical inspector of the Marine-Hospital Service 
before they will be allowed to enter the United States, unless provision 
shall have been made by State or municipal quarantine laws and regu- 
lations for such examination. 

"2. All persons arriving from Canada, by rail or otherwise, must 
be examined by such medical inspector before they will be allowed to 
enter the United States, unless provision has been made for such 
examination. 

"3. All persons coming from infected districts, not giving satis- 
factory evidence of protection against small-pox, will be prohibited 
from proceeding into the United States until after such period as the 
medical inspector, the local quarantine, or other sanitary officer duly 
authorized, may direct. 

"4. The inspectors will vaccinate all unprotected persons, who 
desire or are willing to submit to vaccination, free of charge. Any 
such person refusing to be vaccinated shall be prevented from entering 
the United States. 

"5. All baggage, clothing, and other effects, and articles of mer- 
chandise, coming from infected districts, and liable to carry infection, 
or suspected of being infected, will be subjected to thorough disinfec- 
tion. 

"6. All persons showing evidence of having had small-pox or 
varioloid, or who exhibit a well-defined mark of recent vaccination, 
may be considered protected; but the wearing-apparel and baggage 
of such protected persons who may come from infected districts, or 
have been exposed to infection, will be subjected to thorough disin- 
fection as provided. 

"7. Customs officers and United States medical inspectors will 
consult and act in conjunction with authorized State and local health 
authorities so far as may be practicable, and unnecessary detention 
of trains or other vehicles, persons, animals, baggage, or merchandise, 
will be avoided so far as may be consistent with the prevention of the 



548 TEXT-BOOK OF HYGIENE. 

introduction of disease dangerous to the public health into the United 
States. 

"8. Inspectors will make full weekly reports of services performed 
under this regulation. 

"9. As provided in Section 5 of said act, all quarantine officers 
or agents acting under any State or municipal system, upon the appli- 
cation of the respective State or municipal authorities, are empowered 
to enforce the provisions of these regulations, and are hereby author- 
ized to prevent the entrance into the United States of any vessel or 
vehicle, person, merchandise, or animals prohibited under the act 
aforesaid. 

"10. In the enforcement of these regulations there shall be no 
interference with any quarantine laws or regulations existing under 
or to be provided for by any State or municipal authority." 

The following are the special instructions for the guidance of 
sanitary inspectors, issued by Surgeon H. W. Austin, in charge of the 
inspection service on the Canadian frontier from Buffalo, N. Y., to 
the Atlantic coast during the epidemic above referred to (see Marine- 
Hospital Report, 1886) :— 

Regulations for Sanitary Inspectors. 

"The following instructions will be observed by the sanitary in- 
spector on the following-mentioned railroads crossing the United 
States boundary-line — viz., the Grand Trunk Railway, at Rouse's 
Point, N. Y., and Island Pond, Yt. ; the Passumpsic Railroad, at 
Xewport, Yt. ; the Central Yermont Railroad, at Highgate Springs 
or Saint Albans; the Canada Atlantic, at Rouse's Point, X. Y., and 
the Southeastern Railway, at Richford, Yt. : — 

"All persons bound for the United States coming from Montreal, 
or other places in Canada where small-pox prevails, must produce 
satisfactory evidence to the inspector that they are protected by a 
recent vaccination, or submit to this operation before they are allowed 
to cross the boundary-line. 

"Inspectors will vaccinate all unprotected persons free of charge. 

"Persons coming from Montreal, or suburban villages, will be 
carefully questioned as to their residence, whether small-pox has 
occurred in their families, or whether they have been in contact with 
the disease. 

"Inquiries should also be made relative to their baggage, whether 
it consists of bedding, household goods, etc., likely to be infected; and 



INLAND QUARANTINE. 549 

if any person or article of baggage is considered by the inspector in- 
fected or likely to introduce the disease into the country, he or it 
should not be permitted to cross the line into the United States. 

"You may consider persons protected who may show evidence of 
having had the small-pox or varioloid, or who exhibit a well-defined 
mark of vaccination. Accept as evidence of protection a certificate 
from any physician in good standing that the person presenting the 
same has been successfully vaccinated. Should you doubt the validity 
or authenticity of the certificate, you may refuse any such person 
presenting the same the privilege of crossing the border unless he 
submits to vaccination. Baggage known to have come from any in- 
fected district, and believed to be infected, will be thoroughly fumi- 
gated with sulphur at Eouse's Point, Saint Albans, Eichford, New- 
port, and Island Pond. 

"Weekly reports should be made to Surgeon H. W. Austin, 
United States Marine-Hospital Service, Burlington, Vt., of the num- 
ber of trains inspected, number of persons examined, number of per- 
sons vaccinated, number of pieces of baggage fumigated, and any 
other information relative to services performed by the inspector." 

It will be observed that all the railroads, five in number, over 
which passengers or freight might be brought direct from Canada 
into the New England States, were guarded. 

Besides the line commanded by Surgeon Austin (Atlantic coast 
to Buffalo), another line was under the direction of Passed Assistant 
Surgeon Wheeler, at points east of Buffalo, and still another on the 
Michigan frontier, under command of Surgeon W. H. Long. These 
lines were established at the request and with the co-operation of the 
authorities of the respective States. Thirty-six inspectors were em- 
ployed at 37 stations, who examined 49,631 persons on railroad-trains, 
vaccinated 16,547, and detained or sent back 603. The contents of 
more than 7000 pieces of baggage were disinfected. The measures 
taken were successful. 

In 1893, at a time when there was imminent danger that cholera 
might be introduced into the sea-board cities of the United States 
and carried by immigrants to the far West and the interior cities and 
towns, a most carefully formulated plan of railroad medical inspec- 
tion of immigrants was drawn up; and while it was, fortunately, 
never necessary to carry out the provisions made at the time, the fol- 
lowing regulations will well show the scope and general design of the 
protective and restrictive measures contemplated: — 



550 TEXT-BOOK OF HYGIENE. 

Eailroad Medical Inspection of Immigrants. 

Treasury Department, 
Office of the Supervising Surgeon-General United States 
Marine-Hospital Service, 

Washington, August 23, 1893. 

Instructions for the Guidance of Medical Officers of the Marine-Hos- 
pital Service, Sanitary Inspectors, and others concerned. 

1. One or more medical inspectors shall accompany immigrants 
from the point of departure of each immigrant train, and shall im- 
mediately commence making a careful inspection of ever}' passenger — 
man, woman, and child — upon the train. This inspection shall consist 
in identifying each passenger with the health card or cards he or she 
may hold, and satisfying himself as to the health of each person at the 
time of said inspection. He shall pass through the train once every 
hour or oftener, if he has reason to believe any person is suffering 
with diarrhoea or other symptoms of cholera. 

2. The railroad companies will be expected to furnish earth- 
closets, which should be used, and the regular closets of the car are 
to be locked. These earth-closets shall be destroyed, before the train 
reaches it destination, at such points as the railroad officials shall 
designate. It shall be the duty of the inspector to see that the earth- 
closets are kept clean and frequently disinfected, and the cars prop- 
erly ventilated and free from all offensive odors and dirt. 

3. He shall, upon the least suspicion of cholera among the im- 
migrants, have the suspected person or persons immediately removed 
to the hospital car at the rear of the train, disinfect all ejecta, and 
take every precaution possible to prevent the spread of the disease 
among the passengers by thoroughly disinfecting that portion of the 
car occupied by the suspects, the simplest means for this purpose being 
a solution of bichloride of mercury in the proportion of 1 to 800. 

4. The inspectors will at once notify the conductor of the train 
upon the first appearance of a suspicious case, in order that the hos- 
pital car may be switched off at the first designated switch, and the 
health officer of the county in which said switch is located be imme- 
diately notified to take charge of this car. 

5. It is expected that the railroads will furnish a car for hospital 
purposes, in which the seats can be readily converted into beds suit- 
able for the care of the sick. The necessary bedding will be furnished 
by the United States Marine-Hospital Service. 

6. Disinfectants, consisting of packages of bichloride of mercury 



INTERSTATE QUARANTINE. 551 

and an alkali, will be furnished the medical inspector in proper quan- 
tities for adding to a two-gallon wooden bucket of water ; also a quan- 
tity of carbolic acid in solution and other approved disinfectants. 
Each hospital car shall be equipped with a dozen two-gallon wooden 
buckets for holding disinfecting fluids, half a dozen mops, one or more 
hand force-pumps with rose sprinklers, one or more commodes and 
bed-pans, half a dozen eight-ounce hard-rubber syringes, half a dozen 
tumblers, one dozen rubber sheets, and one dozen feeding-cups for 
administering medicine. There shall also be furnished an oil-stove 
for heating water, and several tin boilers and tin cups. 

7. Medical supplies, etc., consisting of tannic acid, hydrarg. chlo- 
ridum mite, tincture of opium, mustard or mustard papers, chloro- 
form or ether sulph., whisky, brandy, and one or more hypodermic 
syringes; also supply of Squibb's Diarrhoea Mixture for checking 
looseness of the bowels or premonitory diarrhoea. 

Walter Wyman", 
Supervising Surgeon-General. 

INTERSTATE QUARANTINE. 

The general principles governing interstate quarantine are the 
same as those pertaining to the maritime and foreign quarantines, 
with the exception that, instead of dealing with ships as the media 
of transportation, we must deal with trains on railroads, lines of 
stage-coaches, and steam-boats plying on the inland waters of the 
United States. The principles are almost sufficiently elaborated in 
the previous sections on train inspection in the case of yellow-fever 
epidemics, and the precautions which were under consideration for the 
prevention of the spread of cholera by means of emigrant trains. 

An important matter is the one of notification. It will be seen, 
by a study of the regulations for interstate quarantine which follow, 
that State and municipal health officers are requested to notify the 
Supervising Surgeon-General of the appearance of any of the quar- 
antinable diseases in their States or localities, thus enabling appro- 
priate measures to be taken to prevent their spread without the loss 
of valuable time, for time in the management of epidemics is of the 
utmost importance. Many an epidemic which has assumed vast pro- 
portions would, if recognized in time, have been capable of easy man- 
agement and of being confined to the seat of its first outbreak. It is 
always comparatively easy to confront an open enemy; it is the in- 
sidious spread of disease, either unrecognized or concealed for reasons 



552 TEXT-BOOK OF HYGIENE. 

of business polic}', that causes delay in the inception of preventive 
measures, and is most to be dreaded from a sanitary standpoint. 

The following are the regulations prepared in the Marine-Hos- 
pital Bureau to prevent the introduction of contagious diseases into 
one State or Territory or the District of Columbia from another State 
or Territory or District of Columbia. It is expected that additional 
regulations will be promulgated from time to time as circumstances 
demand : — 

Interstate Quarantine. 

article i. quarantine diseases. 

1. For the purpose of these regulations the quarantinable diseases 
are cholera (cholerine), yellow fever, small-pox, typhus fever, leprosy, 
and plague. 

ARTICLE II. — NOTIFICATION. 

1. State and municipal health officers should immediately notify 
the Supervising Surgeon- General of the United States Marine-Hos- 
pital Service, by telegraph or by letter, of the existence of any of the 
above-mentioned quarantinable diseases in their respective States or 
localities. 

ARTICLE III. GENERAL REGULATIONS. 

1. Persons suffering from a quarantinable disease shall be iso- 
lated until no longer capable of transmitting the disease to others. 
Persons exposed to the infection of a quarantinable disease shall be 
isolated, under observation, for such a period of time as may be nec- 
essary to demonstrate their freedom from the disease. 

All articles pertaining to such persons, liable to convey infection, 
shall be disinfected as hereinafter provided. 

2. The apartments occupied by persons suffering from quaran- 
tinable disease, and adjoining apartments, when deemed infected, 
together with articles therein, shall be disinfected upon the termina- 
tion of the disease. 

3. Communication shall not be held with the above-named per- 
sons and apartments, except under the direction of a duh 7 -qualified 
officer. 

4. All cases of quarantinable disease, and all cases suspected of 
belonging to this class, shall be at once reported by the physician in 
attendance to the proper authorities. 

5. No common carrier shall accept for transportation any person 



INTERSTATE QUARANTINE. 553 

suffering with a quarantinable disease, nor any infected article of 
clothing, bedding, or personal property. 

Bodies of persons who have died from any of the said diseases 
shall not be transported save in hermetically-sealed coffins, and by the 
order of the State or local health officer. 

6. In the event of the prevalence of small -pox, all persons exposed 
to the infection, who are not protected by vaccination or a previous 
attack of the disease, shall be at once vaccinated or isolated for a period 
of fourteen days. 

7. During the prevalence of cholera, all the dejecta of cholera 
patients shall be at once disinfected, as hereinafter provided, to pre- 
vent possible contamination of the food- and water-supply. 

ARTICLE IV. YELLOW FEVER. 

In addition to the foregoing regulations contained in Article I, 
the following special provisions are made with regard to the preven- 
tion of the introduction and spread of yellow fever: — 

1. Localities infected with yellow fever, and localities contiguous 
thereto, should be depopulated as rapidly and as completely as pos- 
sible, so far as the same can be safely done ; persons from non-infected 
localities, and who have not been exposed to infection, being allowed 
to leave without detention. Those who have been exposed, or who 
came from infected localities, shall be required to undergo a period of 
detention and observation of ten days, from the date of last exposure, 
in a camp of probation or other designated place. 

Clothing and other articles capable of conveying infection shall 
not be transported to non-infected localities without disinfection, i.e., 
inspection to determine the presence of possibly infected mosquitoes, 
and appropriate measures of fumigation- to destroy them. 

2. Persons who have been exposed may be permitted to proceed 
without detention to places willing to receive them, and incapable of 
becoming infected, when arrangements have been perfected to the 
satisfaction of the proper health officer to insure their detention in 
said places for a period of ten days. 

3. The suspects who are isolated under the provisions of para- 
graph 1, Article III, shall be kept free from all possibility of infection. 

4. So far as possible the sick should be removed to a central loca- 
tion for treatment. 

5. Buildings in which yellow fever has occurred, and localities 
believed to be infected with said disease, must be disinfected as thor- 
oughly as possible. 



554 TEXT-BOOK OF HYGIENE. 

6. As soon as the disease becomes epidemic, the railroad-trains 
carrying persons allowed to depart from the city or place infected with 
yellow fever shall be under medical supervision. 

7. Common carriers from the infected districts, or believed to be 
carding persons and effects capable of conveying infection, shall be 
subject to sanitary inspection, and such persons and effects shall not 
be allowed to proceed, except as provided for by paragraph 2. 

8. At the close of an epidemic the houses where sickness has 
occurred, and the contents of the same, and houses and contents that 
are presumably infected, shall be disinfected as hereinafter prescribed. 

ARTICLE V. DISINFECTION. 

For Cholera. 

1. The dejecta and vomited matters of cholera patients shall be 
received into vessels containing an acid solution of bichloride of mer- 
cury (bichloride of mercury, 1 part; hydrochloric acid, 2 parts; 
water, 1000 parts) or other efficient germicidal agent. 

2. All bedding, clothing, and wearing-apparel soiled by the dis- 
charges of cholera patients shall be disinfected by one or more of the 
following methods : — 

(a) By complete immersion for thirty minutes in one of the 
above-named disinfecting solutions. 

(b) By boiling for fifteen minutes, all articles to be completely 
submerged. 

(c) By exposure to steam at a temperature of 100° to 102° C. 
for thirty minutes after such temperature is reached. 

3. Any woodwork or furniture contaminated by cholera dis- 
charges shall be disinfected by thorough washing with a germicidal 
solution as provided in paragraph 1, Article V. 

For Yellow Fever. 

4. Apartments infected by occupancy of patients sick with yellow 
fever shall be disinfected by one or more of the following methods : — 

(a) By thorough washing with one of the germicidal solutions 
mentioned. If apprehension is felt as to the poisonous effects of the 
mercury, the surfaces may, after two hours, be washed with clear 
water. 

(b) Thorough washing with a 5-per-cent. solution of pure car- 
bolic acid. 



INTERSTATE QUARANTINE. 555 

(c) By sulphur dioxide, twenty-four to forty-eight hours' expo- 
sure, the apartments to be rendered as air-tight as possible. 

5. Bedding, wearing-apparel, carpets, hangings, and draperies 
infected by yellow fever shall be disinfected by one of the following 
methods : — 

(a) By exposure to steam at a temperature of 100° to 102° C. 
for thirty minutes after such temperature is reached. 

(b) By boiling for fifteen minutes, all articles to be completely 
submerged. 

(c) By thorough saturation in a solution of bichloride of mer- 
cury, 1 to 1000, the articles being allowed to dry before washing. 

Articles injured by steam (rubber, leather, containers, etc.), to 
the disinfection of which steam is inapplicable, shall be disinfected 
by thoroughly wetting all surfaces with (a) a solution of bichloride 
of mercury 1 to 800, or (b) a 5-per-cent. solution of carbolic acid, the 
articles being allowed to dry in the open air prior to being washed 
with water, or (c) by exposure to sulphur fumigation in an apart- 
ment air-tight, or as nearly so as possible. 

(Eecent investigations have proved that in disinfection for yellow 
fever less attention need be paid to fomites, but more to the exter- 
mination of mosquitoes.) 

For Small-pox. 

6. Apartments infected by small-pox shall be disinfected by one 
or both of the following methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(b) Washing with a solution of bichloride of mercury 1 to 1000, 
or a 5-per-cent. solution of pure carbolic acid. 

7. Clothing, bedding, and articles of furniture exposed to the 
infection of small-pox shall be disinfected by one or more of the fol- 
lowing methods: — 

(a) Exposure to sulphur dioxide for twent}^-four to forty-eight 
hours. 

(b) Immersion in a solution of bichloride of mercury 1 to 1000, 
or a 5-per-cent. solution of pure carbolic acid. 

(c) Exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature is reached. 

(d) Boiling for fifteen minutes, the articles to be completely 
submerged. 



556 TEXT-BOOK OF HYGIENE. 

For Typhus Fever. 

8. Apartments infected by typhus fever shall be disinfected by 
one or both of the following methods: — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(b) Washing with a solution of bichloride of mercury 1 to 1000, 
or a 5-per-cent. solution of pure carbolic acid. 

9. Clothing, bedding, and articles of furniture exposed to the 
infection of typhus fever, shall be disinfected by one or more of the 
following methods : — 

(a) Exposure to sulphur dioxide for twenty-four to forty-eight 
hours. 

(b) Immersion in a solution of bichloride of mercury 1 to 1000, 
or a 5-per-cent. solution of pure carbolic acid. 

(c) Exposure to steam at a temperature of 100° to 102° C. for 
thirty minutes after such temperature is reached. 

(d) Boiling for fifteen minutes* the articles to be completely sub- 
merged. 

(Lately fumigation with formaldehyde gas has taken the place 
of sulphur dioxide.) 

MUNICIPAL QUARANTINE. 

It is now generally conceded that a small number of cases of 
certain ones of the quarantinable diseases may exist in a city of con- 
siderable size, without giving rise to serious apprehension, if intelli- 
gent and vigorous measures for the prevention of its spread are taken, 
and if scientific measures for the isolation of patients, the surveillance 
of those exposed to infection, and the disinfection of apartments and 
articles infected are carried out. It is regarded as very important 
that the sick should be removed to centrally-located hospital estab- 
lishments for treatment, thus increasing ease of management and 
administration, and diminishing the number of foci of infection. The 
surveillance of those exposed to infection should, in general, be for a 
period of time equal to the usual period of incubation of the disease 
to which they have been exposed. In the case of small-pox it may 
be unnecessary at times to detain the suspects the full period of in- 
cubation, provided they are vaccinated and their clothing and per- 
sonal effects are rendered safe by efficient disinfection. They should, 
however, be kept under observation. 

For the suppression of small-pox in cities in which it has made 



MUNICIPAL QUARANTINE. 557 

its appearance, and in which it threatens to become epidemic, the 
following suggestions, made by the health authorities of the North- 
west, will undoubtedly prove of value: — 

1. The city should be divided into districts containing not more 
than 10,000 people. 

2. Each district should be placed under the supervision of a com- 
petent medical inspector with necessary assistants (a) to make a 
house-to-house inspection; (b) to successfully vaccinate, within the 
shortest possible time, all persons who have not been vaccinated dur- 
ing the outbreak, the first vaccination to be completed within seven 
days; (c) to properly disinfect all houses and their contents where 
small-pox occurs. 

3. Necessary means and appliances for efficient disinfection of 
materials, premises, etc., should be provided as the exigencies of each 
district may require. 

4. Each case of small-pox should be immediately removed to a 
suitably constructed and properly equipped and officered isolation hos- 
pital. 

5. Except in extreme cold weather, hospital tents, as prescribed 
in the United States Army Eegulations, floored and warmed, are 
preferable to the average hospital or private dwelling, and increase 
the chances of recovery of the patients. Cases of small-pox neces- 
sarily retained in their own homes should, with their attendants, be 
rigidly isolated during the period of danger, and physicians visiting 
such patients professionally should be subject to such regulations as 
may be prescribed by the local health officer. 

6. Persons exposed to small-pox contagion should be immediately 
vaccinated and kept under observation for not less than fourteen days 
from time of last exposure. 

7. It is the sense of this Conference that unless such measures 
are enforced, it will be necessary for neighboring cities and States to 
exclude all persons from such city who are not protected against small- 
pox by recent vaccination, and to require proper disinfection of all 
clothing, baggage, and merchandise capable of conveying small-pox 
infection. 

The subject of municipal quarantine naturally suggests a sub- 
division of the subject, viz., domiciliary quarantine, or the exercise of 
restrictive measures against a particular house or part of a house on 
account of the occurrence of a quarantinable disease within its limits. 
These can best be accomplished by the stationing of guards to see that 
none enter or leave the infected premises except those necessary to 



558 TEXT-BOOK OF HYGIENE. 

care for the sick, viz., physicians and nurses. All intercourse between 
the outside world and the house under quarantine should be carried 
on by messengers who should not be allowed to enter the premises, 
but who should report to the guards. 

It would be most desirable that the physicians and nurses, on 
leaving the premises, should practice personal disinfection of hands, 
at least ; though, of course, it would be better if, in addition to this, 
a change into sterile clothing were made prior to coming into contact 
with the public. 

It goes without saying that the room of the patient should be 
absolutely closed to the ingress of all save the physicians and nurses, 
and it is a practice of considerable value to provide all room-openings 
with curtains or hangings, which are to be kept constantly wet with 
a germicidal solution. The dejecta, vomited matter, and sputum 
should be promptly disinfected according to circumstances. When 
the disease has terminated, the house or apartments are to be thor- 
oughly disinfected by one of the methods prescribed in the regula- 
tions, the method chosen being adapted to the disease which has pre- 
vailed. For the purposes of municipal disinfection the Marine-Hos- 
pital Service has had constructed portable apparatus for the use of 
steam and sulphur, which are, in effect, the same apparatus as have 
been previously described in this article, modified to meet their special 
requirements. 

An important factor in the measures taken to suppress any epi- 
demic disease is a house-to-house inspection, to ascertain the actual 
number of cases existing. Whether this inspection should include the 
whole city, or only the infected district, is a matter for the exercise 
of judgment; but, when required, the inspections should be made at 
intervals corresponding with the usual periods of incubation of the 
disease under observation. 

A very important field for the exercise of municipal and domi- 
ciliary quarantine is furnished by those contagious and infectious 
diseases which, while causing large mortality, seldom prevail in epi- 
demic form, viz., measles, scarlet fever, diphtheria, and tuberculosis. 

MEASLES. 

Measles may be dismissed with a few words. The course of the 
disease, uncomplicated, is usually so benign, especially in children, 
that all that is necessary is isolation. At the conclusion of the case 
or cases the apartment should be well aired, and it may be advisable 



DIPHTHERIA AND SCARLET FEVER. 559 

to subject the room and the contents, bedding, and clothing to fumi- 
gation by sulphur or formaldehyde. 

DIPHTHERIA AND SCARLET FEVER. 

With diphtheria and scarlet fever the conditions are far different. 
The diseases are virulent: the infection is subtle, and their spread 
very much to be dreaded. Vigorous effort alone can prevent their 
spread. Dwellings where the disease prevails must be placarded, spe- 
cial hospitals should be provided, and disinfection should be intelli- 
gently performed by competent municipal authority. 

The regulations of the Board of Health of the District of Co- 
lumbia are given here, as embodying the more recent practice in the 
management of these diseases: — 

Regulations to Prevent the Spread of Diphtheria and 
Scarlet Fever. 

"The following regulations, provided for in the Act of Congress 
approved December 20, 1890, are promulgated for the information 
of all concerned: — 

"The act referred to provides, in Section 2, 'That it shall be the 
duty of the health officer, in conjunction with the attending physician, 
to cause the premises to be properly disinfected, and to issue the 
necessary instructions for the isolation of the patient; in Section 3, 
'That it shall be the duty of physicians, while in attendance upon 
cases of scarlet fever and diphtheria, to exercise such reasonable pre- 
cautions to prevent the spread of the said diseases as may be prescribed 
by the health officer of the District of Columbia in regulations'; in 
Section 6, 'That the word "regulations," as herein used, shall be held 
to mean, also, rules, orders, and amendments/ 

"The term 'scarlet fever/ as applied in the act, shall be held to 
include scarlatina, scarlet rash, and canker rash, and each and every 
case must be reported upon the forms provided. 

"Warning-signs shall remain displayed on houses, in cases of 
scarlet fever, for a period of not less than four weeks, and in cases 
of diphtheria for not less than three weeks from date of report to 
the health officer, and for a longer period, unless report of recovery 
by the physician in attendance has been made. 

"In cases of death, the warning-sign shall remain displayed upon 
premises for a period of not less than seven days, and longer, unless 
the health officer is satisfied that all proper means have been employed 
for prevention of the spread of the contagion. 



560 TEXT-BOOK OF HYGIENE. 

"It shall be the duty of the householder, in every case where a 
warning-sign has been displayed from the premises which he or she 
occupies, to report promptly the removal of such sign at any time 
within the periods given. 

"It shall be the like duty of the physician in attendance to make 
such report to the health officer of the removal of warning-signs, 
unless assured that the report has been made by some one from the 
premises where the disease is prevailing or has prevailed. 

"It shall be the duty of the physician in attendance to report, 
in every instance, on the forms provided, whether or not children in 
the family or other children in the same building attend school, and 
at what school-building or buildings. 

"Children shall not be permitted to return to school from in- 
fected premises, except upon presentation of the proper certificate 
from the health officer. 

"All persons suffering from either diphtheria or scarlet fever are 
to be isolated in rooms as far removed as possible from those occupied 
by other persons in the building, and upon the top floor, where it is 
practicable. No person, other than the physician in attendance, the 
examining official, and the nurse or nurses, shall be admitted to such 
room during the prevalence of the disease. 

"Every room occupied by a patient suffering from either diph- 
theria or scarlet fever shall be cleared of all needless clothing, carpets, 
drapery, and other materials likely to harbor the poisons of the 
disease. 

"Soiled bed- and bod3 T -linen shall be immediately placed in ves- 
sels of water containing a solution of bichloride of mercury, chloride 
of zinc, or other suitable disinfectant. 

"Excremental discharges from the patient shall be received in 
vessels of water containing such a solution, and all vessels used shall 
be kept scrupulously clean and thoroughly disinfected. 

"Discharges from the throat, nose, and mouth shall be received 
upon pieces of cloth, which must be immediately burned. 

"All persons recovering from either diphtheria or scarlet fever 
shall be considered dangerous, and shall not be permitted to associate 
with others, or to attend school, church, or any public assembly, until 
a certificate has been furnished by the health officer to the effect that 
they may go abroad without danger of disseminating the contagion. 

"It shall be the duty of the person in charge of the premises 
where a case of diphtheria or scarlet fever exists, to exercise all rea- 
sonable care in the prevention of the commingling of persons w r ho 



DIPHTHERIA AND SCARLET FEVER. 561 

come into contact with the patient, or any other persons, whereby the 
contagion might be disseminated. 

"The body of a person who died from either diphtheria or 
scarlet fever shall be immediately disinfected and placed in a coffin, 
which shall be tightly closed, and shall not be taken to any church 
or place of public assembly, and shall be buried within forty-eight 
hours, unless otherwise ordered by the health officer. 

"No public funeral shall be held in a dwelling in which there is 
a case of either diphtheria or scarlet fever, nor in which a death from 
either of said diseases has recently occurred. 

"Immediately upon the recovery of a person who has been suf- 
fering from either diphtheria or scarlet fever, or upon the death of 
a person who has been so suffering, the room or rooms occupied shall 
be thoroughly disinfected by exposure for several hours to the fumes 
of chlorine gas, or of burning sulphur, and shall thereafter be thor- 
oughly cleaned and exposed to currents of fresh air. 

"All clothing, bedding, carpets, and other textiles which have 
been exposed to the contagion of the disease shall be either burned, 
exposed to superheated steam, or thoroughly boiled. 

"No person shall interfere with or obstruct the entrance, inspec- 
tion, and examination of any building or house, by the inspectors or 
officers of this department, when there has been reported the case of 
a person sick with either scarlet fever or diphtheria therein." 

Diagnosis of Diphtheria. — For the more prompt and certain 
diagnosis of diphtheria, small wooden boxes are distributed to the 
various pharmacies in Washington, each box holding two glass tubes, 
one tube containing a small cotton swab, the other containing solidi- 
fied blood-serum as a culture medium. Each tube is sterilized and 
plugged with cotton. The following notice is inclosed in each box: — 

Directions for Making Cultures in Suspected Cases of 
Diphtheria. 

"The patient should be placed in the best light attainable, and, 
if a child, properly held. In cases where it is possible to get a good 
view of the throat, depress the tongue and rub the cotton swab gently, 
but freely, against any visible pseudomembrane or exudate. 7 

"In other cases, including those in which the exudate is confined 
to the larynx, open the mouth and pass the swab back till it reaches 



7 This should be done before any germicide has been applied, and, if 
this has been done, allow at least an hour to intervene before making the 
inoculation. 



562 TEXT-BOOK OF HYGIENE. 

the pharynx, and then rub it freely against the mucous membrane. 
Without laying the swab down, withdrew the cotton plug from the 
culture-tube, insert the swab, and rub that portion of it which has 
touched the exudate gently back and forth along the surface of the 
blood-serum. Then replace the swab in its own tube, plug both tubes, 
and send the whole outfit at once to the laboratory. 

"A report will be forwarded the following morning, by mail, or 
can be obtained by telephone." 

TUBERCULOSIS. 

With the discovery by Koch of the cause of tuberculosis, and the 
numerous researches made by him and other observers into the nature 
of the tuberculous poison, has grown conviction, of late years, that 
tuberculosis, being communicable, is to a large extent preventable. 
The bacillus tuberculosis, is the etiological factor of most importance 
in the spread of tuberculosis; it has been proved that it is contained 
in large numbers in the sputum of tuberculous patients, and that, 
unlike most microorganisms, its vitality is not destroyed by drying. 
Therefore, with the careful disinfection or destruction of the ex- 
pectoration of tuberculous patients, one most important factor in the 
dissemination of tuberculosis will be removed. In almost all large 
hospitals, at the present day, the practice obtains of either isolating 
the tuberculous patients or of segregating them in special wards or 
apartments. With a view of preventing the spread of tuberculosis, 
the Board of Health of New York City has issued in English, Ger- 
man, Hebrew, and Italian the following circular for popular instruc- 
tion : — 

"Consumption is a disease which can be taken from others, and 
is not simply caused by colds. A cold may make it easier to take the 
disease. It is usually caused by germs which enter the body with the 
air breathed. The matter which consumptives cough or spit up con- 
tains these germs in great numbers; frequently millions are dis- 
charged in a single day. This matter, spit upon the floor, wall, or 
elsewhere, is apt to dry, become pulverized, and float in the air as 
dust. This dust contains the germs, and thus they enter the body 
with the air breathed. The breath of a consumptive does not contain 
the germs, and will not produce the disease. A well person catches 
the disease from a consumptive only by in some way taking the matter 
coughed up by the consumptive. 

"Consumption can often be cured if its nature is recognized early 



TUBERCULOSIS. 563 

and proper means are taken for its treatment. In a majority of cases 
it is not a fatal disease. 

"It is not dangerous for other persons to live with a consumptive 
if the matter coughed up by the consumptive is at once destroyed. 
This matter should not be spit upon the floor, carpet, stove, wall, or 
street, or anywhere except into a cup kept for that purpose. The cup 
should contain water, so that the matter may not dry, and should 
be emptied into the closet at least twice a day, and carefully washed 
with hot water. Great care should be taken by a consumptive that 
his hands, face, and clothing do not become soiled with the matter 
coughed up. If they do become soiled, they should be at once washed 
with hot water and soap. When consumptives are away from home, 
the matter coughed up may be received on cloths, which should be at 
once burned on returning home. If handkerchiefs are used (worth- 
less cloths which can be burned are far better), they should be boiled 
in water by themselves before being washed. 

"It is better for a consumptive to sleep alone, and his bed-cloth- 
ing and personal clothing should be boiled and washed separately 
from the clothing belonging to other people. 

"Whenever a person is thought to be suffering from consumption, 
the name and address should be sent at once to the health depart- 
ment, on a postal card, with a statement of this fact. A medical in- 
spector from the health department will then call and examine the 
person to see if he has consumption, providing he has no physician, 
and, if necessary, will give proper direction to prevent others from 
catching the disease. 

"Frequently a person suffering from consumption may not only 
do his usual work without giving the disease to others, but may also 
get well, if the matter coughed up is properly destroyed. 

"Rooms that have been occupied by consumptives should be thor- 
oughly cleaned, scrubbed, whitewashed, painted or papered before they 
are again occupied. Carpets, rugs, bedding, etc., from rooms which 
have been occupied by consumuptives, should be disinfected. The 
health department should be notified, when they will be sent for, dis- 
infected, and returned to the owner free of charge ; or, if he so desire, 
they will be destroyed." 

In view of the possibility that patients convalescing from diph- 
theria may harbor the bacilli for some time after disappearance of 
clinical symptoms, it is advisable to maintain quarantine until two 
successive cultures show the absence of diphtheria bacilli from the 
throat. 



564 TEXT-BOOK OF HYGIENE. 

THE SANATORIUM TREATMENT OF TUBERCULOSIS. 

As a restrictive measure against the spread of tuberculosis, the 
sanatorium treatment of the disease affords results which are hardly 
less gratifying than the curative effects of such treatment. This will 
be readily appreciated when it is remembered that every consumptive 
in his home is a possible and potential focus for the dissemination 
of the infection, and that when he is removed to a sanatorium there 
is one less center of infection to be dealt with. It has been demon- 
strated that under judicious and scientific administration the con- 
sumptive sanatorium does not become itself infected, and that the 
patients under the influence of a liberal dietary, life practically in 
the open air, regulated exercise and regular habits of life, improve 
or become actually cured in a percentage of cases which is very grati- 
fying, and affords strong grounds for hope in the gradual abolition 
of pulmonary tuberculosis. 

The results attained in the treatment of tuberculosis at the Fort 
Stanton Sanatorium, Fort Stanton, N. M., are thus summarized by 
Surgeon P. M. Carrington, who is in command of the station : — 

"1. Given a sufficient length of stay recovery may be expected 
in a very large percentage in first stage uncomplicated cases. 

"2. Eecovery or arrest may be expected in a fair proportion of 
second and third stage cases and all the afebrile cases in which there 
remains sufficient sound lung tissue to support life, but we should 
exercise caution lest we be premature in pronouncing second and third 
stage cases cured, 

"3. Eesults in permanent febr^e cases, especially those in which 
there is a wide range of daily temperature, are not better than in less 
favorable climates. 

"4. Hemorrhages seem less liable at this altitude than at the 
sea-level. 

"5. Heredity plays an unimportant part in the causation of the 
disease." 



QUESTIONS TO CHAPTER XX. 

QUARANTINE. 

What is meant by quarantine? From what is the term derived? Has 
it now any definite limitation as to time? To what is the term applied? 
What are the two natural divisions of quarantine? What are the principal 
quarantinable diseases? What determines the length of quarantine for each 
of these? Should tuberculosis be quarantinable? 

What is meant by foreign quarantine? What regulations are now to be 
observed at foreign ports by vessels clearing for the United States? What 
officers have charge of this foreign quarantine? 

What are some of the points considered in the bill of health? What are 
some of the requirements with regard to vessels and their cargoes? Regard- 
ing passengers and crew? What are the objects of the inspection card given 
to passengers? 

What requirements are to be observed at sea? What method is pre- 
scribed for the disinfection of vessels? Of cargoes? What can be said of the 
efficiency of the foregoing regulations? 

What is meant by domestic quarantine? What will govern the equip- 
ment of a maritime quarantine station? What are required at a fully- 
equipped station? What is the method of construction of the most recent 
steam disinfecting chambers, and in what ways are they superior to the 
earlier models? What precautions are to be observed in operating them? 
What is the principle of construction of the sulhpur-furnaces now used at 
quarantine stations, and wherein are they superior to other methods of 
producing sulphurous-acid? How is the gas to be conveyed into the holds of 
vessels, etc.? What apparatus is provided for using germicidal solutions 
Where barracks are necessary, how should they be arranged and equipped? 
What facilities for bathing should be provided? What is to be said of the 
water-supply ? 

What regulations are to be observed at ports of entry and on the fron- 
tier? What points are covered by the inspection, and what vessels are exempt 
from inspection? What vessels are to be quarantined, and for how long? 
What are the general requirements at quarantine? What treatment must 
cholera-infected vessels undergo in quarantine? What is the prescribed method 
of disinfection? What routine is to be observed with passengers detained on 
account of cholera? 

Under what conditions may traffic be allowed from ports infected with 
yellow fever? What inspection is required of State and local quarantines? 
What regulations govern the Canadian and Mexican frontiers? What are 
some of the points to be observed in the successful management of a quar- 
antine station? 

(565) 



566 TEXT-BOOK OF HYGIENE. 

What is the treatment required for cholera-infected vessels? What 
special measures are to be taken against cholera? Who has supreme com- 
mand of a cholera camp, and how is it to be divided? What are the regu- 
lations to be observed in the detention camp? In the hospital camp? Why 
should infected dejecta and ejecta be disinfected immediately upon discharge? 

How many national quarantine stations are there, and where are they 
located? Give a brief description of those in the Delaware Bay and River. 
What government vessel is used as a quarantine station? 

What are some of the aids to national quarantine? What inspection 
is required of all quarantines? What is required of all State and local quar- 
antines? What are the instructions, both general and special, to the officers 
detailed to inspect State and local quarantines? 

What is meant by inland quarantine? By the sanitary cordon? When 
and where has the latter been employed in the United States, and with what 
success? W 7 hat is a camp of probation? What is the difference between it 
and a camp of refuge? How should a camp of probation be equipped, man- 
aged, and guarded? What should be the daily routine of such a camp? What 
regulations should be promulgated and enforced for such a camp? Have 
these camps been efficacious in preventing the spread of disease ? 

What is the purpose of railroad quarantine, and how is it to be carried 
out? How may it be facilitated by train-inspection service? What rules are 
to be adopted for railway quarantine? What action has been taken to pre- 
vent the introduction of small-pox, etc., from Canada? What are the regula- 
tions issued for the guidance of sanitary inspectors? What provisions are 
there for the medical inspection of immigrants on board trains? 

What general principles govern interstate quarantine? What are the 
regulations covering it? W 7 hich of these is the most important? What spe- 
cial provisions are made respecting yellow fever? What are the methods of 
disinfection prescribed, respectively, for cholera, yellow fever, small-pox, and 
typhus fever? 

What are the essential points of municipal quarantine? What precau- 
tions are to be taken to rrevent the spread of small-pox, measles, diphtheria, 
ai.d scarlet fever? To what extent should domiciliary quarantine be carried? 
How long should it be maintained? 

How may a diagnosis of diphtheria be made? What means may be 
taken to prevent the spread of tuberculosis? 

Give a synopsis of the quarantine laws of the United States. What is 
the maximum penalty for attempting to enter a port in evasion of them? 
What information of value to quarantine officers, etc., is furnished weekly? 
When and by whom may travel and traffic from infected ports and places be 
prohibited ? Who has supreme charge of the enforcement of the quarantine 
regulations? In what department of the government does the supervision of 
quarantine belong? 



INDEX. 



Abscesses, resume of, 437. 
Acclimatization to diminished air-pres- 
sure, 9. 
Actinomycosis, 434. 

resume of, 438. 
Acute infectious diseases, propagation of, 

7, 16. 
Adulteration of foods, 147, 148. 
Air, 1. See also Atmosphere, 
absorption of heat and aqueous vapor 

by, 4. 
ammonia in, 27. 
bacteria in, 6. 
bacteriological examination of, 31. 

quantitative, 33. 
carbon dioxide in, limit of, allowable, 

38. 
carburetted hydrogen in, 27. 
-currents, sanitary relations of, 16. 
determination of organic matter in, 33. 
dry, in the causation of respiratory dis- 
eases, 14. 
dust in, 28. 
carrying bacteria, 28. 
in cities, 28. 
examination of, 29. 
for ammonia, 37. 
for bacteria, 31. 

for carbon dioxide, author's method, 
34. 
Boom's method, 33. 
Pettenkofer's method, 35. 
for carbon monoxide, 37. 
for gases, 37. 
for organic matter, 33. 
for ozone, 30. 

Houzeau's test for, 30. 
for solid impurities, 30. 

Dixon's method, 30. 
for sulphur, 37. 

substances to determine in, 29. 
exhausting, from old wells and privy- 
vaults, 28. 
ground-, 161. 

impurities in respired, where found, 41. 
infection by contaminated, 7. 
-passages, diseases of, caused by low 

temperature, 13. 
-pressure, acclimatization to diminished, 
9. 
effect of diminished, 8. 
purity of, in wells and privy-vaults, test 
for, 29. 



Air, questions to Chapter I on, 43. 
sanitary relations of changes in com- 
position and impurities of, 
23. 
source of, for ventilation, 39. 
-space, dimensions of, per person, 39. 
initial, 39. 

Morin's table showing proper propor- 
tion of, 40. 
sulphuretted hydrogen in, 27. 
-tester, 34. 
warmth of, 4. 

wind caused by differences in pressure 
of, 6. 
Ale, 143. 

Alcohol, abstainers and users of, table of 
expectation of life of, 141. 
amount of, in various medicines, 144. 
as a beverage, 143. 
ale, 143. 
beer, 143. 
brandy, 142. 
brown-stout, 143. 
forms of, 142. 
gin, 142. 
kumys, 143. 
porter, 143. 
whisky, 142. 
wine, 142. 
adulteration of foreign, 142. 
beverages containing, 138. 
"deadly parallel" between food and, 139. 
fatality of croupous pneumonia in users 

of, 141. 
influence of, upon the mortality from 
nervous diseases, table 
showing, 141. 
pathological effect of, 140. 
physiological effect of, 138. 
predisposition to disease in habitual 

users of, 141. 
therapeutic effect of, 138. 
Alimentary - averages, 138. 
Alkaloidal beverages. See Beverages, 

Alkaloidal. 
Altitude, atmospheric pressure in relation 
to, table showing, 3. 
high, effects of, 8. 
Alum, examination for, in bread, 155. 
Ammonia, albuminoid, in water, deter- 
mination of, 101. 
free, in water, determination of, 101. 



(567) 






IXDEX. 



Ammonia in air, 27. 

determination of, 37. 
in sewer-air, 27. 
in water, source of, 82. 
poisoning by, 250. 
Anchorages, 489. 

Aniline vapor, poisoning by, 257. 
Animals, diseases of, due to conditions of 

the soil, 169. 
Annatto, test for, 152. 
Anthrax, 435. 

resume of, 438. 
Antiseptics, disinfectants, and deodorants, 
447. 
antiseptics, table of, 459. 
definitions of, 447, 448. 
deodorizers, 460. 

disinfectants for clothing, bedding, etc., 
450. 
for excreta, 450. 
for furniture, etc., 451. 
• for merchandise and the mails, 451. 
for non-spore-containing matter, 449«- 
for rags, 451. 
for railway cars, 452. 
for ships, 452. 

for spore-containing matter, 449. 
for the dead, 451. 
for the person, 451. 
for the sick-room and hospital wards, 

451. 
formaldehyde, 456. 
and potassium permanganate, 457. 
danger of, 458. 
two classes of, 449. 
disinfection of clothing, 453. 
of excreta, 452. 
of ingesta, 455. 

of privy-vaults, cess-pools, etc., 455. 
of the person, 453. 
of the sick-room, 454. 
questions on, 461. 
resistance of certain bacteria to, table of, 

448. 
table of antiseptics, 459. 
Artesian wells, 61. 
Artificial sea-bath, recipe for ingredients 

of, 359. 
Asiatic cholera, history of, 409. 
Atmosphere, certain diseases communi- 
cable by, 7. See also Air. 
composition and physical conditions of, 

2. 
effect of rarefied, on phthisis, 10. 
electrical and magnetic conditions of, 6. 
humidity of, connected with changes in 

health, 16. 
infection of, by coughing, sneezing, 

speaking, and exhaling, 7. 
influence of electrical conditions of, 
upon health, 17. 



Atmosphere, varieties of pathogenic bac- 
teria found in, 28. 
Atmospheric pressure, 3. 
causes of variations in, 3, 4. 
increased, 11. 

effects of, 11. 
influence of changes of, on health, 7. 
relation of humidity to, 4. 
relation of, to altitude, table showing, 3. 

Bacilli, typhoid, in ice, 54. 

Bacillus coli, effect of solutions of metals 

upon, 81. 
Bacteria in air, 6. 

examination for, 31. 
harmless, 7. 
pathogenic, 7. 
putrefactive, 7. 
role of dust in carrying, 7. 
in drinking-water. See Water, Drink- 
ing-, 
in sewer-air, 27. 

of non-putrefactive decomposition, 166. 
table showing resistance of certain, to 

disinfectants, 448. 
varieties of pathogenic, found in air, 28. 
Bactericidal action of metals, 81. 
Bacteriological examination of water, 105. 
Bacterium of non-putrefactive decomposi- 
tion, 166. 
of putrefaction, 166. 
Baker, H. B., observations on relation of 
respiratory diseases to low 
temperature, 13. 
Baking, broiling and, 137. 
Barometric pressure, effect of, 10. 
Barracks, 493. 
Bath-house, 493. 

Baths and bathing. See Personal Hygiene. 
Battlefield, interment on, 372. 
Beans, 134, 135. 
Beer, 143. 

Beverages, alimentary, 138. 
alkaloidal, 145. 
chocolate, 146. 

nutritive properties of, 146. 
coffee, 145. 
adulteration of, 146. 
artificial, 145. 
tea, 146. 
adulteration of, 146. 
containing alcohol, 138. See also Alco- 
hol. 
Bilge-water. See Marine Hygiene. 
Birth-rate and death-rate, 466. 
Births, registration of, 464. 
Bisulphide of carbon, poisoning by, 253. 
Boarding-station, 489. 

-vessel, 489. 
Boiling, 136. 
Bovine tuberculosis, 435, 



INDEX. 



569 



Brandy, 142. 

Bread. See Foods of Vegetable Origin. 

Broiling and baking, 137. 

Bromine and iodine vapors, poisoning by, 

254. 
Brown-stout, 143. 
Building-site, 194. 

Burial grounds, supposed dangers of, 370. 
Butter. See Foods of Animal Origin. 

Caisson disease, 11. 

prevention of, 11. 
Calorie, 113. 

definition of, 113. 
Camp diseases, 279. 
hygiene, military and. See Military and 
Camp Hygiene. 
Camps, sanitary care of, 277. 
Candles, 203. 

Carbon bisulphide, poisoning by, 253. 
dioxide, determination of, 33. 
effects of, 24, 25. 
excess of, in water, effect of, on lead 

pipes, 78. 
in water, dangerous proportion of, 78. 
poisoning by, 252. 

proportion of, in the atmosphere, 38. 
allowable, 23, 24. 
monoxide, 26. 
poisoning by, 251. 
test for, 37. 
Carburetted hydrogen, "fire-damp," in the 
air, 27. 
poisoning by, 252. 
Carriers of infection, 387. 
Casualties and disabilities due to ship- 
wreck, 296. 
Cerebro-spinal meningitis, epidemic, his- 
tory of, 429. 
Cess-pools as sources of contamination, 
50. 
disinfection of, 455. 
Cider, 143. 

Chalk strata in relation to hygiene, 196. 
Chart, acute lung diseases, 19. 
consumption, 18. 

cause of death of seafaring people, 292. 
diarrheal diseases, 20. 
diphtheria and croup, 22. 
diseases of seafaring people, 293. 
typhoid fever, 21. 
Cheese. See Foods of Animal Origin. 
Chimney as a ventilator, 41. 
Chlorine-gas, poisoning by, 251. 
Chocolate, 146. 
Choke-damp, 29, 252. 

poisoning by, 252. 
Cholera, Asiatic, history of, 409. 
epidemic of, at Hamburg, 85. 
in soldiers, 283. 
resume of, 438. 



Cholera, special measures against. See 
Quarantine. 

spirillum in water, 77. 

transmitted by drinking-water, 76. 

vessels. See Quarantine. 
Cisterns, above ground, 50. 

underground, 50. 
contamination of, 50. 
Clay, dense marls, and alluvial soils, 197. 

slate, the, 196. 
Climate and diarrheal diseases, 12. 
Clothing. See Personal Hygiene. 

disinfection of, 453. 
Coal-gas, composition of, 26. 
Coca, 146. 
Coffee, 145. 

ground, adulteration of, 146. 
Cold, respiratory diseases caused by, 13. 
Color of water, 100. 

significance of, 100. 
Construction of habitations, 192. 

of hospitals, 219. 
Contagion and infection, 385. 

carriers of infection, 387. 

differentation of, 385. 

incubation period of infectious diseases, 
table of, 386. 

period of infectiousness of patient, 387. 

questions on, 390. 
Cooking, 136. 

Copper and other metals, bactericidal ef- 
fect of, 81. 
Creamometer, 123, 124. 
Cremation. See Dead, Disposal of. 
Crematory, 494. 
Cultivated soils, 197. 
Cysticercus cellulosa in meat, 129. 

Danger from lead pipe as a conductor of 

water, 78. 
Dead, disposal of, 369. 
cremation, 371. 
entombment in vaults, 371. 
interment, 369. 

on the battlefield, 372. 
methods of, 369. 
questions on, 373. 

supposed dangers of burial grounds, 
370. 
Death-rate among persons living in dif- 
ferent stories of houses, 193. 
among young children as a result of 

overcrowding, 194. 
and birth-rate, 466. 

relation of, to density of population, 
table on, 192. 
Deaths, registration of, 466. 
Decomposition, non-putrefactive, bacte- 
rium of, 166. 
Dengue, history of, 427. 
Deodorants, 447. 



570 



INDEX. 



Deodorization of contents of privies, 173. 
Deodorizers, 460. 
Dermatitis from sun's rays, 12. 
Diarrhea in soldiers, 279. 
Diarrheal diseases in the summer, 12. 
Diminished air-pressure, effect of, 8. 
Diphtheria, diagnosis of, 561. 
directions for making cultures in sus- 
pected cases of, 561. 
history of, 426. 
quarantine of, 559. 
resume of 438. 
Disease, diminution of, due to drainage of 
wet soil, 194. 
germ theory of, 374. 
questions on, 384. 
mosquito transmission of, management 
of epidemics of yellow fever 
in the light of, 542. 
Diseases, acute infectious, propagation of, 
7, 16. 
camp, 279. 

contagious and infectious, Vacher's table 
of the time-periods of, 241. 
Whitelegge's table showing periods of 
quarantine after, 242. 
due to absorption or local action of irri- 
tating or poisonous sub- 
stances, 261. 
constrained attitude and sedentary life, 

265. 
excessive use of certain organs, 263. 
exposure to elevated or variable tem- 
perature or atmospheric 
pressure, 263. 
exposure to mechanical violence, 265. 
impure drinking-water, 64. 
inhalation of irritating or poisonous 
dust, 258. 
gases or vapors, 250. 
epidemic, history of, 391. 

cerebro-spinal meningitis, epidemic, 

429. 
cholera, Asiatic, 409. 
dengue, 427. 
diphtheria, 426. 
gonorrhea, 433. 
influenza, epidemic, 428. 
measles, 425. 
meningitis, cerebro-spinal, epidemic, 

429. 
questions on, 442. 
relapsing fever, 419. 
scarlet fever, 425. 
small-pox, 396. 
inoculation, 399. 
vaccination, 401. 
Jenner, Edward, 402. 
sweating sickness, 395. 
syphilis, 430. 
typhoid fever, 420. 



Diseases, epidemic, typhus fever, 421. 
yellow fever, 423. 
in hot climates, 12. 
in infants, 26. 
incident to school life, 235. 
infectious, resume of some of the, 437. 
abscesses, 437. 
actinomycosis, 438. 
anthrax, 438. 
cholera, 438. 
diphtheria, 438. 
dysentery, 438. 
glanders, 438. 
gonorrhea, 439. 
hydrophobia, 439. 
influenza, 439. 
leprosy, 439. 
malaria, 439. 
measles, 439. 
mumps, 439. 
parotitis, 439. 
pertussis, 441. 
plague, 439. 
pneumonia, 439. 
rabies, 439. 
relapsing fever, 440. 
scarlet fever, 440. 
small-pox, 440. 
syphilis, 440. 
tetanus, 440. 
typhoid fever, 440. 
typhus, 440. 
tuberculosis, 440. 
whooping-cough, 441. 
yellow fever, 441. 
most frequent in prisons, 350. 
of animals communicable to man, 434. 
actinomycosis, 434. 
anthrax, 435. 
bovine tuberculosis, 435. 
glanders, 437. 
questions on, 446. 
rabies, 435. 
sheep-pock, 434. 
tuberculosis, bovine, 435. 
probably due to similar conditions of the 

soil, 169. 
quarantinable, 473. 

table of, 473. 
registration of, 465. 
spread by soil impurities, 116. 
Disinfectants. See Antiseptics, Disinfec- 
tants, and Deodorants. 
Disinfecting chambers, steam, 490. 

sulphur-furnace, 491. 
Disinfection by germicidal solutions, 492. 

of ships. See Marine Hygiene. 
Disposal of the dead. See Dead. 
Dixon's aeroscope, 30. 
Drains, best material for, 170. 
depth for, 170. 



INDEX. 



571 



Drains, trees for, 170, 198. 
Drainage, 170. 
of ships. 13ee Marine Hygiene, 
-pipe, 170. 
Drinking-water, 62. See also Water, 
Drinking-, 
contamination of, by excrement, 50. 
from ice and snow, 62. 
limit of solid matter allowable in, 63. 
sources of, 50. 
Dust, diseases due to inhalation of irri- 
tating or poisonous, 258. 
coal-dust, 258. 
metallic dust, 258. 
mineral dust, 258. 
vegetable dust, 259. 
in air, 28. 

carrying bacteria, 28. 
nature of, 31. 

occupations concerned in making, 249. 
Dwellings. See Habitations. 
Dysentery in soldiers, 279. 
resume of, 438. 

Earth-closet, 177. 

Effluvia from cemeteries and knackeries, 
27. 

Eggs. See Foods of Animal Origin, 
from persons and discharges of sick in 
air, 38. 

Electric light, 204. 

Electrical and magnetic conditions of the 
atmosphere, 6. 

Epidemic cerebro-spinal meningitis, his- 
tory of, 429. 
diseases in hot climates, 12. 
influenza, history of, 428. 

Epidemics, typhoid, due to contaminated 
water-supply, 66-76. 

Erythema from sun's rays, 12. 

Eucalyptus tree for draining soil, 170, 198. 

Examination, bacteriological, of water. 
See Water, 
of food, 150. 
of water, 93. 

Excrement contaminating drinking-water, 
50. 

Excreta, disinfection of, 452. 

Exercise and training. See Personal Hy- 
giene. 

Fat in milk. See Foods of Animal Origin. 
Fever, relapsing. See Relapsing Fever. 

scarlet. See Scarlet Fever. 

typhoid. See Typhoid Fever. 

typhus. See Typhus Fever. 

yellow. See Yellow Fever. 
Filters, comparative utility of slow sand 
and mechanical, 92. 

domestic, 81. 

mechanical, 90. 



Filters, mechanical, chemicals used with, 
91. 
cleansing of, 91. 
efficiency of, 92. 
principles of, 90. 
slow sand, construction of, 84, 85. 
first in America, 88. 
Filtration, 81. 
conclusions of R. Koch upon, 86. 
Dr. A. Robin's conclusion from experi- 
ments at Wilmington, Del., 
87-88. 
slow sand, 84. 
effect of, 84. 

general installation of, 88, 90. 
principles of, 84. 
summary of experiments upon, 87. 
table of comparative mortality before 
and after, 88, 89. 
Fire-damp, 252. 
dangers of, 252. 
in mines, 27. 
Flies, danger from, in quarantine, 526. 
Food, 110. 
adulteration of, 147, 148. 
adulterations of, table showing detection 
of, in one year in Illinois, 
149. 
albuminoid proximate principles of, 117. 
caloric value of, to calculate, 115. 
calorie, 113. 
carbohydrates, 118. 
definition of, 110. 

dietaries, standard, Hutchison's, 114-115. 
dietary, for adult male of average 
weight, table of, 111. 
standards of, 111. 
examination of, 150. 
butter, 152. 
oleomargarine, 153. 
insoluble fatty acids, 154. 
melting-point, 154. 
specific gravity, 153. 
flour and bread, 154. 
for alum, 155. 
for copper sulphate, 155. 
for ergot, 155. 
for gluten in, 154. 
for mineral substances, 155. 
for water and ash, 154. 
milk, 150. 
for annatto, 152. 
for boric acid, 152. 
for cane-sugar, 152. 
for formaldehyde, 152. 
for percentage of ash, 151. 
for percentage of fats, 151. 
for sodium carbonate, 152. 
for total solids, 151. 
fat, 118. 
increased combustion of, 118, 119. 



572 



INDEX. 



Food, greater consumption of carbohy- 
drates during exercise, 118. 
in prisons, 350. 

materials of average prices, table of 
comparative cost of digesti- 
ble nutrients and energy in 
different, 112. 
nutrition, physiology of, 111. 
nutritive ingredients of, table of, 116. 
principles, alimentary, 110. 

proximate, 110. 
proximate principles of, 110. 
quantity and character of, necessary, 110. 
fats or carbohydrates, 111. 
proteids, 111. 
salts, 110. 
water, 110. 
quantity of any single one necessary 

for existence, 117. 
questions to Chapter III on, 156. 
ration, an ideal, 115. 
reduced, of Chittenden, 115. 
of Chittenden, experiments with, 116. 
relation of climate to, 117. 
relative proportion of, for men and 
women, 113. 
of nitrogenous to non-nitrogenous, 
principles, 113. 
standard dietaries, Hutchison's, 114-115. 
unit of measurement of the fuel-value 

of, 113. 
uses of nutrients in body, 117. 
water and other inorganic proximate 
principles of, 118. 
Foods, classification of, 119. 
of animal origin, 119. 

adulteration of, 147, 148. 
butter, 120, 125. 
cheese, 125. 
relative value of different, in ali- 
mentary principles, 126. 
eggs, 133. 

cooked, digestibility of, 133. 
fish, oysters, crabs, and lobsters, 
poisoning by, 130. 
poisoning by, siguatera, 130. 
meat, 126. 
changes in, after death. 127. 
parasites in, 128. 
ptomaines in, 129. 
putrefaction of, 129. 
soluble preparations of, 127, 128. 
table of relative proportions of fat 

and proteids in, 127. 
tainted, prevention of disease 

from, 132. 
tuberculous, 131. 
unfit, 128, 129, 131, 132. 
prevention of disease from, 132. 
ptomaines in, 129. 
milk, 119. 



Foods, of animal origin, milk, adultera- 
tion of, 121. 
determination of the quality of, 123. 
infection by, 121, 122, 123. 
skim-milk, 121. 
specific gravity of, 124. 
tyrotoxicon in, 124. 
whey, 120. 
oleo-margarine, 125. 
"swill-milk*" 123. 
of vegetable origin, 133. 
adulteration of, 147, 148. 
bread, 133. 

substitutes for, 134. 
condiments, 136. 
flour, adulteration of, 134. 
fruits and nuts, 135. 
green vegetables, 135. 
leguminous seeds, 134. 

composition of, 135. 
rye, disease due to, 134. 
Foodstuffs, caloric value of, 115. 
Formaldehyde as a disinfectant, 456. 
with potassium permanganate, 457. 
danger of, 458. 
Frost-bite, 13. 
Frying, 137. 
Fungi, lower, in air, 6. 

Gases from putrefaction, poisoning by, 253. 
or vapors, irritating or poisonous, dis- 
eases due to inhalation of, 
250. 
ammonia, 250. 
aniline vapor, 257. 
bisulphide of carbon, 253. 
bromine vapor, 254. 
carbon bisulphide, 253. 

dioxide, 252. 

monoxide, 251. 
carburetted hydrogen, 252. 
choke-damp, 252. 
chlorine gas, 251. 
copper vapors, 256. 
fire-damp, 252. 
gases from putrefaction, 253. 
hydrochloric-acid gas, 250. 
hydrogen, carburetted, 252. 

sulphuretted, 253. 
iodine and bromine vapors, 254. 
lead poisoning, 254. 
mercurial poisoning, 255. 
methane, 252. 
nitric-acid fumes, 250. 
petroleum vapor, 254. 
sulphuretted hydrogen, 253. 
sulphurous-acid gas, 250. 
turpentine vapor, 254. 
zinc or copper vapors, 256. 
Gas-light, 204. 
Germicidal solutions, disinfection by, 492. 



INDEX. 



573 



Gin, 142. 
Glanders, 437. 

resume of, 438. 
Gonorrhea, history of, 433. 

resume of, 439. 
Granitic, metamorphic, and trap rocks, 

the, 195. 
Gravels, 196. 
Ground-air. See Soil, Atmosphere of. 

-water. See Water, Ground-. 
Guarana, 146. 

Gymnastic training, tables showing effects 
of, on development, 355, 357. 

Habitations, construction of, 192. 
character of the soil, 195. 
chalk, 196. 
clay, dense marls, and alluvial soils, 

197. 
clay slate, 196. 
cultivated soils, 197. 
granitic, metamorphic, and trap 

rocks, 195. 
gravels, 196. 
limestone and magnesium limestone 

rocks, 196. 
sands, 196. 
sandstones, 196. 
house-drainage, 205. 
water-closets, 206. 
house-drain, 215. 
soil pipe, 214. 
traps, 212. 

water-supply for, 211. 
interior arrangements, 196, 200. 
size of rooms, ventilating and heat- 
ing, 200. 
wall-coating, 203. 
lighting, 203. 
materials, 198. 
questions on, 217. 
site, 194. 
unsanitary, effects of, upon young 

children, 194. 
water-supply, 205. 
official supervision of the sanitary ar- 
rangements of, 216. 
Hardness of water. See Water. 
Health and life, relation of occupations 
to, 246. 
effect of changes of temperature on, 
11, 12. 
prevention of, 12. 
of continual inhalation of sewer-air 
upon, 27. 
humidity of atmosphere connected with 

changes of, 16. 
influence of changes of atmospheric 

pressure on, 7. 
occupations prejudicial to, 249. 
Heat, effects of great, 263. 



History of epidemic diseases. See Dis- 
eases, Epidemic, History of. 
marine hygiene, 285. 
Hospital, general, administration and 

management of, 226. 
Hospitals, construction of, 219. 

administration building, 226. 
buildings, 219. 
bathrooms, 224. 
dead-house, 225. 
dining-room, 225. 
disinfecting chest, 225. 
fireproof material in ceilings, 224. 
floors, 223. 
Johns Hopkins Hospital as a model, 

220, 221. 
kitchen, 225. 
laundry, 226. 
pavilion system, 220. 
questions on, 228. 
site, 219. 

ventilation and heating, 22is. 
ward-kitchens, 225. 
water-closets, 224. 
water-supply, 225. 
House, material for building, 198. 
Houses. See Habitations. 
Humidity, absolute, 5. 
low absolute, a cause of respiratory dis- 
eases, 13. 
of atmosphere connected with changes of 

health, 16. 

relation of, to atmospheric pressure, 4. 

to temperature, table showing, 5. 

Hydrants, out-door, 78. 

Hydrochloric acid gas, poisoning by, 250. 

Hydrogen, carburetted, in the air, 27. 

poisoning by, 252. 
Hydrogen, sulphuretted, in the air, 27. 

poisoning by, 253. 
Hydrophobia. See Rabies. 
Hygiene, industrial, 246. 
marine. See Marine Hygiene, 
military and camp. See Military and 

Camp Hygiene, 
personal. See Personal Hygiene, 
prison. See Prison Hygiene. 
school. See School Hygiene. 

Ice, 53. 

contaminated, 54. 
snow, 54. 
Illuminating gas, carbon monoxide in, 26. 

chronic poisoning with, 26. 
Immunity, theories of, 379. 
Ehrlich's, ""2. 
Metchnikoff's, 381. 
questions on, 384. 
Impurities in water, 63. 

a&il, diseases spread by, 116. 
Industrial hygiene, 246. 



574 



INDEX. 



Industrial hygiene, questions on, 266. 
Infection by contaminated air, 7. 

carriers of, 887. 
Influenza, epidemic, history of, 428. 

r#sunie of, 439. 
Ingesta, disinfection of, 455. 
Interment. See Dead, Disposal of. 
Iodine and bromine vapors, poisoning by, 
254. 

Kefyr, 143, 144. 
Kerosene, 203. 
Kumys, 143, 144. 

Lactodensimeter, 124. 

Lactometer, 123. 

Lactoscope, 123. 

Lead pipes as conductors of water, dan- 
gers of, 78. 
poisoning, 254. 

Legumes, 134, 135. 

Lentils, 134, 135. 

Lepr resume of, 439. 

Life and health, relation of occupations 
to, 246. 
expectation of, in abstainers and users 
of alcohol, table of, 141. 

Lighting, 203. 

Limestone and magnesium limestone 
rocks, the, 196. 

Malaria, resume of, 439. 

Malarial fevers in soldiers, 280. 

Man, diseases of animals communicable 

to. See Diseases. 
Marine hygiene, 285. 

bilge, composition of, 307. 
tables of, 308. 

-water, of the boiler-room, 311. 
of the cambuse, 311. 
of the engine-room, 311. 
of the store-room, 311. 
drainage of ships, 297. 
battleships, 297. 
bilge-water, 297. 
tables of variation of composition 
of 307, 309, 310. 
summary, 301. 
surface drainage, 300. 
two methods of, 297. 
historical, 285. 

morbidity and mortality occurring in 
seafaring people, 288. 
casualties and disabilities due to 
shipwreck, 296. 
tables of, 296, 297. 
charts of, 292, 293. 
health of the navy and marine corps 

of the United States, 290. 
tables of, 290, 291, 294, 295. 



Marine hygiene, navy ration, 325. 

tables of, 328, 329, 330, 331, 332. 
questions on, 347. 
ship, the, 312. 
cleanliness, 318. 
dry decks, 319. 
table showing benefit of, 319. 
construction, 312. 
battleship, air-space of, table of, 
318. 
plan of, 315. 
disinfection, 320. 
carbon dioxide, 325. 
formaldehyde, 323. 
lime, 324 

mercuric chloride, 324. 
steam, 323. 
sulphur, 322. 
ventilation, 338. 
different methods of, 340. 
systems of Idaho and Mississippi, 
342. 
tables of, 345, 346. 
water-supply, 332. 
allowance of, per man, 336. 
analysis of, table showing, 335. 
contamination of, 336. 
distilled, table of, 335. 
distillers, 332. 
scuttle-butt, 337. 
Marriages, registration of, 465. 
Mate, 146. 

Measles, history of, 425. 
quarantine of, 558. 
resume of, 439. 
Meat. See Foods of Animal Origin. 
Mechanical filters. See Filters. 
Meningitis, cerebro-spinal, epidemic, his- 
tory of, 429. 
Mercurial poisoning, 255. 
Methane, poisoning by, 252. 
Methods of purification of sewage, 186. See 
Sewage, Methods of Purifi- 
cation. 
Micro-organisms in sewer-air, 28. 
Military and camp hygiene, 268. 
camp diseases, 279. 
cholera, 283. 
diarrhea, 279. 
dysentery, 279. 
malarial fevers, 280. 
phthisis, 283. 
scurvy, 283. 
typhoid fever, 282. 
typhus fever, 283. 
venereal diseases, 283. 
yellow fever, 282. 
hospital tents, 276. 
mosquitoes, 281. 
questions on, 284. 



INDEX. 



575 



Military and camp hygiene, sanitary care 
of camps, 277. 
the clothing of the soldier, 272. 
the dwelling of the soldier, 274. 

tents, 276. 
the food of the soldier, 270. 
table showing components of, 270- 

271. 
table showing calories of (German 
army), 271. 
the recruit, 268. 
the training of the soldier, 269. 
Milk. See Foods of Animal Origin. 
Mineral waters in this country, classifica- 
tion of, 55. 
table showing analyses of some of the 
more popular, 60. 
Mines, fire-damp in, 27. 
Model study room, 232. 
Moore, J. M., observations on relation 
of respiratory diseases to 
low temperature, 14. 
Morin's table for air-space, 40. 
Mortality among residents of badly con- 
structed dwellings, 192. 
from typhoid fever, table of, 90. 
from various diseases, table showing in- 
fluence of alcohol upon, 141. 
table of comparative, before and after 

filtration, 88, 89. 
typhoid, average, in cities supplied with 
filtered water, 76. 
in American cities, table showing, 72- 
75. 
Mosquito, danger from, in quarantine, 526. 
influence of, upon the management of 

yellow fever, 541. 
transmission of disease, management of 
epidemics of yellow fever, 
in the light of, 542. 
Mosquitoes and camp-life, 281. 
Moulds in air, 6. 

spores of, in air, 6. 
Mountain sickness, 9. 
Mumps, resume of, 439. 
Municipal quarantine. See Quarantine. 

National quarantine. See Quarantine. 
Naval hygiene. See Marine Hygiene. 
Nervous disorders in school-children, 239. 
Nitrates and nitrites in water. See 

Water. 
Nitric-acid fumes in factories, 250. 
Nitrogen in atmospheric air, 2. 

Occupation neuroses, 264. 
Occupations concerned in making dust, 
249. 

hygiene of. See Industrial Hygiene. 

prejudicial to health, 249. 



Occupations, relation of, to health and 
life, 246. 
table showing average age of certain, 247. 
Odor of water, 101. 

significance of, 101. 
Oleo-margarine. See Foods of Animal 

Origin, Butter. 
Organic matter in water. See Water. 
Overcrowding in cities, 192, 193. 
relation of, to pulmonary tuberculosis, 
193. 
Oxygen and carbon dioxide in ground-air. 

See Soil, Atmosphere of. 
Oxygen in atmospheric air, 2. 
Ozone in atmosphere, 6, 30. 
test for, 30. 

Paraguay tea, 146. 
Parasites in meat, 128. 

cysticercus cellulosa, 129. 
trichina spiralis, 128. 
Parkes and Kenwood's table of daily quan- 
tity of water required by 
human beings, 47. 
Parkes's rules for ventilation, 41. 
Parotitis, resume of, 439. 
Patent medicines, amount of alcohol in 

various, 144. 
Peas, 134, 135. 
Pellagra, 134. 
Perflation, 40. 

Person, disinfection of, 453. 
Personal hygiene, 353. 

baths and bathing, 357. 
cold, 358. 
taken when heated or perspiring, 
359. 
cramps, 360. 

drowning, methods of resuscitation 
for, 360. 
Michigan, 361. 
Sylvester's, 360. 
free, 362. 
questions on, 367. 
rules for, 359. 
sea-bathing, 358. 

artificial, recipe for, 359. 
tepid, warm, or hot, 358. 
clothing, 363. 
absorption of gases and vapors by, 

365. 
color, 364. 
dyes, 365. 
fit, 365. 

materials for, 363. 
animal skins, 364. 
cotton, 363. 
leather, 364. 



576 



INDEX. 



Personal hygiene, clothing, materials for, 
linen, 363. 
silk, 364. 
wool, 363. 
non-inflammable, process of render- 
ing, 365. 
questions on, 368. 
exercise and training, 353. 
amount required, 356. 
overexertion, 356. 
questions on, 367. 

tables showing effect of gymnastic 
training on development, 
355, 357. 
questions on, 367. 
recreation and rest, 366. 
Petroleum vapor, effects of, 254. 
Pettenkofer's method for determining car- 
bon dioxide in air, 35. 
Phthisis, effect of rarefied atmosphere on, 
10. 
in soldiers, 283. 
Pioscope, 123. 

Plague, oriental, history of, 391. 
resume of, 439. 
-vessels. See Quarantine. 
Flans of intake and water-tower in Wil- 
mington, Del., 83. 
of slow sand filters, 85. 
of storage reservoir in Wilmington, Del., 
82. 
Pneumonia, croupous, fatality of, in users 
of alcohol, 141. 
resume of, 439. 
Poisoning by absorption or local action of 
irritating or poisonous sub- 
stances. See Poisonous Sub- 
stances, 
by inhalation of gases or vapors. See 

Gases, etc. 
chronic, with illuminating gas, 26. 
Poisonous dust, diseases due to the in- 
halation of irritating or, 
258. 
gases or vapors, diseases due to the 
inhalation of irritating or, 
250. 
substances, diseases' due to the absorp- 
tion or local action of irri- 
tating or, 261. 
alkali, strong, 262. 
arsenic, 261. 

bichromate of potassium, 262. 
glass-blowers, 262. 
petroleum, 262. 
phosphorus, 261. 
potassium bichromate, 262. 
quinine, 262. 



Population, density of, table on relation 

of death-rate to, 192. 
Porter, 143. 

Principles, alimentary, 110. See Food. 
Proximate, 110. See Food. 
Prison hygiene, 348. 

diseases most frequent in prisons, 350. 
exercise, 350. 
food, 350. 
punishment, 350. 
questions on, 352. 
reform, principles of, 348. 
site for, qualities necessary, 350. 
Privies as sources of contamination, 50. 

ventilation of, 173. 
Privy-vaults, disinfection of, 455. 
Ptomaines in meat, 129. 
Prophylaxis against yellow fever on the 
Texas-Mexican border, cam- 
paign of, 543. 
Proteids. See Foods. 
Proximate principles, 110. See Food. 
Pulmonary affections, chronic, conditions 
predisposing to, 25. 
tuberculosis and overcrowding, 193. 
Purification of water, storage and, 77. 
Putrefaction, bacterium of, 166. 
definition of, 369. 
gases from, poisoning by, 253. 

Quarantinable diseases, 473. 

table of, 473. 
Quarantine, 472. 
definition of, 472. 
diseases, quarantinable, 473. 

table of, 473. 
division of, two natural, 473. 
domestic, 488. 
plant for, 489. 
anchorages, 489. 
barracks, 493. 
bath-house, 493. 
boarding-station, 489. 
boarding-vessel, 489. 
crematory, 494. 

disinfection by germicidal solutions, 
492. 
by steam-chambers, 490. 
by sulphur-furnace, 491. 
hospitals, 492. 

steam disinfecting chambers, 490. 
sulphur-furnace, 491. 
water-supply, 494. 
wharves, 489. 
regulations, 495. 
disinfectants, authorized and meth- 
ods of use, 508. 
application of, in quarantine work, 
512. 



INDEX. 



577 



Quarantine, domestic regulations, applica- 
tion of disinfectants, vessel, 
articles injured by steam, 
513. 
bedclothes, 513. 
clothes and room furnishing, 

513. 
cooking and eating utensils, 

514. 
hold of, iron, 512. 
holds of, 513. 
living apartments, 513. 
textiles, soiled, 514. 
gaseous, 509. 
formaldehyde gas, 510. 
sulphur dioxide, 509. 
physical, 508. 
boiling, 508. 
burning, 508. 
steam, 509. 
solutions, chemical, bichloride of 
mercury, 512. 
carbolic acid, 512. 
formalin, 512. 
inspection, 495. 

of State and local, 508, 530. 
preamble, 495. 
quarantine, 497. 
requirements, general, 498. 
special, Canadian and Mexican 
frontiers, 506. 
on account of cholera, 500. 
leprosy, 504. 
plague, 505. 
small-pox, 503. 
typhus fever, 504. 
yellow fever, 501. 
relating to naval vessels, 507. 
stations, maritime, 488. 
flies, danger from, in, 526. 
foreign, 473. 
regulations, 474. 
bills of health, 474, 477. 
exemptions, 477. 
form of, 474-475. 
supplemental, 475,' 477. 
form of, 475-476. 
cargo, 479. 

exemptions, 480. 
efficiency of, 486. 
inspection of vessels, 478. 
passengers and crew, 481. 

inspection card, form of, 483. 
ports exempted on Canadian border, 

477. 
quarantinable diseases, 474. 
records, reports, etc., 484. 
requirements at sea, 484. 
disinfecting solutions, 486. 



Quarantine, foreign regulations, require- 
ments at sea, with regard 
to vessels, 478. 
inland, 533. 
camps of probation, 536. 
Camp Perry, Fla., 537. 

discipline of, 538. 
detention camp, Waynesville, Ga., 
539. 
cordon, the sanitary, 533. 
yellow fever, in Texas, 534. 
interstate, 551. 
notification, 552. 
quarantinable diseases, 552. 
regulations, general, 552. 
disinfection, 554. 
for cholera, 554. 
for small-pox, 555. 
for typhus fever, 556. 
for yellow fever, 554. 
yellow fever, 553. 
mosquito, danger from, in, 526. 
influence of, upon the management oi 

yellow fever, 541. 
transmission of yellow fever, manage- 
ment of epidemics in the 
light of, 542. 
municipal, 556. 
diphtheria, 559. 
diagnosis of, 561. 

directions for making cultures in 
suspected cases of, 561. 
measles, 558. 
scarlet fever, 559. 
tuberculosis, 562. 
sanatorium treatment of, 564. 
plant, quarantine, 489. 
questions on, 565. 

railroad, and inspection service, 544. 
medical inspection of immigrants, 550. 
regulations for sanitary inspectors of, 

548. 
train-inspection service during the 
Brunswick epidemic, 545. 
school, 242. 

service, the national, 527. 
aids to, 529. 

stations on Delaware Bay and River, 
527. 
station, management of, 514. 
cholera, special measure against, 521. 
camp, regulations for, 524. 
detention, 524. 
hospital, 525. 
inspection, 514. 

vessels, cholera, treatment of, 519. 
plague, treatment of, 517. 
yellow fever, treatment of, 515. 
stations, maritime, 488. 



578 



INDEX. 



Quarantine, yellow fever, campaign of 

prophylaxis against, of the 

Texas-Mexican border, 543. 

influence of the mosquito upon the 

management of, 54L 
management of epidemics of, in the 
light of the mosquito trans- 
mission of, 542. 
Quarantines, national inspection of all, 
508, 530. 
instructions to officers making, 530. 
general, 531. 
special, 531. 
Questions to Chapter I, air, 43. 

to Chapter II, water, 107. 

to Chapter III, food, 156. 

to Chapter IV, the soil, 170. 

to Chapter V, removal of sewage, 190. 

to Chapter VI, construction of habita- 
tions, 217. 

to Chapter VII, construction of hospitals, 
228. 

to Chapter VIII, school hygiene, 244. 

to Chapter IX, industrial hygiene, 266. 

to Chapter X, military and camp 
hygiene, 284. 

to Chapter XI, marine hygiene, 347. 

to Chapter XII, prison hygiene, 352. 

to Chapter XIII, personal hygiene, 367. 

to Chapter XIV, disposal of the dead, 
373. 

to Chapter XV, the germ theory of dis- 
ease, 384. 

to Chapter XVI, contagion and infection, 
390. 

to Chapter XVII, history of epidemic 
diseases, 442. 

to Chapter XVIII, antiseptics, disinfec- 
tants and deodorants, 461. 

to Chapter XIX, vital statistics, 470. 

to Chapter XX, quarantine, 565. 

Rabies, 435. 

resume of, 439. 
Ragsorters' disease, 260. 
Rain-water. See Water. 
Ration, navy, 325. 

tables of, 328, 329, 330, 331, 332. 
Recreation and rest. See Personal Hy- 
giene. 
Registration of births, 464. 

deaths, 466. 

diseases, 456. 

marriages, 465. 
Regulations, quarantine. See Quarantine. 
Relapsing fever, history of, 419. 

resume of, 440. 
Removal of sewage, 172. See Sewage. 
Respiratory diseases, relation of cold to 
etiology, of, 13. 



Respiratory organs, certain diseases com- 
municable by, 7. 

Restoration of apparently drowned per- 
sons, 360. 

River-water. See Water. 

Roasting, 137. 

Rum, 142. 

Sands, 197. 
Sandstones, 136. 
Sanitary care of camps, 277. 
Scarlet fever, history of, 425. 
quarantine of, 559. 
resume of, 440. 
School hygiene, 229. 

age to start in school, 235. 
blackboards, 234. 
desks ; 233. 

gymnastic exercises, 235. 
height of schools, 230. 
length of time in school, 235. 
lighting of schools, 232. 
model study room, 232. 
questions on, 244. 
ventilation, 229, £30. 
water-closets, 233. 
-life, diseases incident to, 235. 

causes of pulmonary tuberculosis, 

240. 
communicable, 240. 
defective hearing, 238. 
digestive derangements, 240. 
disordered menstruation, 240. 
near-sightedness, 236. 
nervous, 239, 240. 
spinal curvature, 238. 
Sea-bath, artificial, recipe for, 359. 
Sedentary life, diseases due to, 265. 
Septic tank method of removal of sewage, 

186. 
Sewage, changes taking place in, table 
of, 185. 
deodorization of, 173. 
disposal of, 184. 
methods of purification of, 186. 
bacterial, 186. 
broad irrigation, 186. 
irrigation with copious underdrain- 

age, 186. 
sedimentaticn and irrigation, 186. 
"septic tank," 186. 
sterilization by heat, 186. 
more important bacteria found in, 185. 
purification of, a biological process, 184. 
removal of, 172. 
eartn and ash-closets, 177. 
-closet, comparison of, with water- 
closet, 179. 
midden system, 174. 
questions to Chapter V on, 190. 
pit system, 174. 



INDEX. 



579 



Sewage, removal of, pneumatic system of 
Liernur, 179. 
privy and privy-well system, 173. 

-well system, 174. 
reasons for, 172. 

Rochdale, or pail-closet, system, 175. 
systems of, 173. 
water-carriage systems, 180. 
"combined," 180. 
"separate," 180, 181. 
total quantity of, for each individual, 
172. 
Sewer-air, 27. 
ammonia in. 27. 
bacteria in, 27. 
composition of, 27. 
Sewer-pipe, 170. 
Sheep-pock, 434. 
Ships. See Marine Hygiene. 
Shipwreck, casualties and disabilities due 
to, 296. 
tables of, 296, 297. 
Sick-room, disinfection of, 454. 
Siguatera, 130. 

Site for prisons, qualities necessary, 350. 
Small-pox, history of, 396. See Diseases, 
Epidemic, History of. 
quarantine of, 503. 
resume of, 440. 
Snow-blindness, 13. 
prevention of, 13. 
-water, 50. 
Soil, atmosphere of, 161. 

contamination of, with sewage, 172. 
in relation to diseases, 162. 
micro-organisms in, 163. 
movements of, 163. 
oxygen and carbon dioxide in, 161. 
significance of carbon dioxide in, 164. 
character of, 195. 
physical and chemical, 160. 
in relation to construction of habita- 
tions, 195. 
conditions of, diseases of animals due 

to, 169. 
drainage of, 170. 
drains, best material for, 170. 
eucalyptus tree for, 170, 198. 
sewer-pipe, 170. 
sunflower-plants for, 170, 198. 
impurities, diseases spread by, 166. 
questions to Chapter IV on, 170. 
water of, 165. 

wet, diminution of disease due to, table 
of, 194. 
drainage of, prophylactic against pul- 
monary tuberculosis, 194. 
predisposing to pulmonary tubercu- 
losis, 194. 
sanitary results of drainage of, 194. 
drains, drainage-pipe, 170. 



Soldier, clothing of, 272. 
dwelling of, 274. 
food of, 270. 

infectious diseases of, 279. 
yellow fever, 282. 
typhoid fever, 282. 
malarial fever, 280. 
cholera, 283. 
diarrhea, 279. 
phthisis, 283. 
dysentery, 279. 
venereal diseases, 283. 
training of, 269. 
Solids, total, in water, determination of, 

101. 
Sources of drinking-water, 50. 
Solutions, germicidal, disinfection by, 492. 
Spring-water, 54. 

Statistics, vital. See Vital Statistics. 
Steam disinfecting chambers, 490. 
Still-births among upper-story dwellers, 

193. 
Storage and purification of water, 77. 
reservoir in Wilmington, Del., plans of, 
82. 
Suicide by inhaling fumes of charcoal, 26. 

relation of, to seasons, 23. 
Sulphuretted hydrogen, in the air, 27. 
Sulphur-furnace 491. 
Sulphurous-acid gas, poisoning by, 250. 
Sun's rays, dermatitis from, 12. 
direct influence of, 12. 
erythema from, 12. 
Sun-stroke, 12, 263. 
conditions predisposing to, 12. 
prevention of, 12. 
Sweating sickness, history of, 395. 
Syphilis, history of, 430. 
resume of, 440. 

Table of antiseptics, 459. 

of changes taking place in sewage, 185, 
186. 

of comparative cost of digestible nu- 
trients and energy in dif- 
ferent food materials of 
average prices, 112. 

of deaths from typhoid fever, 90. 

of dietary for adult male of average 
weight, 111. 

of food adulterations for one year in 
Illinois, 149. 

of mineral waters in this country, 55. 

of quarantinable diseases, 473. 

of standard dietaries, Hutchison's, 114- 
115. 

of the time-periods of contagious and 
infectious diseases, Vach- 
er's, 241. 

showing analyses of artesian well water, 
62. 



580 



INDEX. 



Table showing analyses of bilge-water in 
warships, 309, 310. 

analyses of some of the more popular 
mineral waters, 60. 

analyses of water-supply of warships, 
335. 

average age-limit in certain occupa- 
tions, 247, 24S. 

benefits of dry deck cleaning, 319. 

casualties of seafaring people, 296, 297. 

characteristics of waters according to 
de Chaumont's classifica- 
tion, 99. 

comparative expectation of life in 
abstainers and non-abstain- 
ers, 141. 

comparative mortality before and after 
filtration, 88, 89. 

comparison of carbon dioxide and ni- 
trogen excretion of a man 
at rest and at work, 118. 

components of the United States 
Army's rations, 270-271. 

composition of bilge, 308. 

composition of kumys, cows' milk 
kumys, and kefyr, 144. 

composition of legumes, 135. 

cubic air-space on warships, 318. 

daily composition of water in Ameri- 
can cities, 47-49. 

daily quantity of water required by 
human beings, 47. 

effects of gymnastic training on de- 
velopment, 355, 357. 

incubation period of infectious dis- 
eases, 386. 

influence of alcohol upon the mortality 
from various diseases, 141. 

morbidity and mortality of seafaring 
people, 290, 291, 294, 295. 

navy rations, 328, 329, 330, 331, 332. 

nutritive ingredients of food, 116. 

percentage of alcohol in patent medi- 
cines, 144. 

periods of quarantine after contagious 
diseases, Whitelegge's, 242. 

proper proportion of air, 40. 

relation of atmospheric pressure to 
altitude, 3. 

relation of death-rate to density of 
population, 192. 

relation of humidity to temperature, 5. 

relative number of bacteria found in 
series of wells, 61. 

relative proportions of fat and proteids 
in meat, 127. 

relative value of different kinds of 
cheese in alimentary princi- 
ples, 126. 



Table showing resistance of certain bac- 
teria to disinfectants, 448. 
the sanitary result of drainage of wet 

soil, 194. 
typhoid mortality in American cities, 

72-75. 
uses of nutrients in the body, 117. 
variations in composition of bilge- 
water, 307. 
ventilation of warships, 345, 346. 
Tape-worms, ova of, in water, 63. 
Tea, 146. 

Temperature, diseases due to exposure to 
elevated or variable, 263. 
effect of changes of, on health, 11. 
effect of, 11, 12. 
effect of, prevention of, 12. 
low, effects of, 13. 

relation of humidity to, table showing, 5. 
Tents, hospital, 276. 
Tobacco, 146. 
-amaurosis, 146. 
effects of, 146. 
Tetanus, resume of, 440. 
Trichina spiralis in meat, 128. 
Tuberculosis, bovine, 435. 
in soldiers, 282. 

pulmonary, predisposing causes of, 240. 
relation of overcrowding to, 193. 
wet soil, drainage of, as a prophy- 
lactic, 194. 
predisposing to, 194. 
quarantine of, 562. 
resume of, 440. 
sanatorium treatment of, 564. 
Tuberculous meat, 131. 
Turpentine vapors, effects of, 254. 
Typhoid bacilli in ice, 54. 
fever, epidemics of, due to contaminated 
water-supply, 66-76. 
epidemics of, water-borne, 96, 97. 
history of, 420. 
in soldiers, 282. 

mortality average in cities supplied 
with filtered water, 76. 
in American cities, table showing, 72- 
75. 
table of deaths from, 90. 
Typhus fever, resume of, 440. 

history of, 421. 
Tyrotoxicon in milk, 124. 

Vaccination, 401. 
and syphilis, 407. 

moae of performing the operation, 404. 
symptoms, 403. 
Vacher's table of the time-periods of con- 
tagious and infectious dis- 
eases, 241. 



INDEX. 



581 



Vaults, entombment in, 371. 
Vegetable foods, 135. 
Venereal diseases in soldiers, 283. 
Ventilation, 200. 
and heating, 200. 
artificial, 40. 
definition of, 38. 
how accomplished, 40. 
natural, 40. 
of hospitals, 222. 
of privies, 173. 
of schools, 230. 

of ships, 338. See Marine Hygiene. 
Parkes's rules for, 41. 
principles of, 38. 
proper system of, 39. 
questions on, 45. 
source of air for-, 39. 
Ventilators, 200-201. -YN8 
Vessels, cholera. See Quarantine, 
plague. See Quarantine, 
yellow fever. See Quarantine. 
Violence, diseases due to exposure to 

mechanical, 265. 
Vital statistics, 462. 

death-rate and birth-rate, 466. 
questions on, 470. 
registration of births, 464. 
of deaths, 466. 
of diseases, 465. 
of marriages, 465. 

Wall-coating, 203. 
Water, 46. 
albuminoid ammonia in, 95. 
ammonia in, from cattle-manure, 52. 

source of, 96. 
bacteriological examination of, 97, 105. 
media for, 105. 
procedure, 105. 
bilge-. See Marine Hygiene, 
carbon dioxide in, dangerous proportion 
of, 78. 
effect of, on lead pipes, 78. 
excess of, effect of, on lead pipes, 78. 
chemical analysis of, object of, 94. 

objections to, 96. 
ohlorides in, 95. 
classification of, de Chaumont's, 98. 

table of characteristics of, 99. 
clear but containing disease germs, 96. 
-closets, 206. 

water-supply for, 211. 
color of, 63. 
daily consumption of, in American cities, 

table of, 47. 
daily quantity of, required by human 

beings, table of, 47. 
deep well, ammonia in, source of, 96. 

nitrites in, source of, 96. 
drinking-, 62. 



Water-drinking, bacteria in, safe limit of, 
98. 
cholera transmitted by, 76. 
contamination of, by excrement, 50. 
diseases due to impure, 64. 
cretinism, 64. 
diarrhea, 65. 
dysentery, 65. 
parasitic, 66. 
typhoid, 66. 
limit of solid matter allowably in, 63. 
sources of, 50. 
examination of, 93, 100. 
albuminoid ammonia, 101. 
chlorine, 103. 

significance of, 103. 
color, 100. 

significance of, 100. 
for lead, copper, and iron, 104. 
free ammonia, 101. 
hardness, 104. 
nitrates, 102. 

significance of, 102. 
r'trites, 101. 
odor, 101. 

significance of 101. 
organic nitrogen, 101. 
oxygen consumed, 102. 

significance of, 103. 
for phosphates, 105. 
total solids in, 101. 
turbidity, 100. 
significance of, 100. 
filtered, average typhoid mortality In 

cities supplied with, 76. 
freezing, 53. 

from fresh-water lakes and ponds, 53. 
fungi and algas in, 53. 
ground-, 165. 
contamination of, with sewage, 172. 
influence of, on bacteria of decomposi- 
tion, 166. 
on bacteria of putrefaction, 167. 
micro-organisms in, 166. 
hard 64. 
hardness of, 63. 
cause of, 64. 

determination of, 64, 104. 
permanent, 64. 
soap test for, 64. 
temporary, 64. 
total, 64. 
impurities in, 63. 

mineral, in this country, classification 
of, 55. 
table showing analyses of some of the 
more popular, 60. 
nitrates and nitrites in, 95. 

source of, 96. 
nitrites and nitrates in, 95. 
objectionable organic impurities in, 94. 



582 



INDEX. 



Water, organic matter in, 65. 

nitrogen in, 95. 
ova of tape-worm in, 63. 
petroleum in, 63. 
potable, qualities of good, 62. 
proportion in tissues of animal body, 46. 
purification of, by alum, 64, 79. 

by boiling, 78. 

by bromine, 79. 

by copper sulphate, 79. 

by ferrous sulphate and lime, 64. 

Lind*s method, 78. 

by ozone, 93. 

by potassium permanganate, 79. 
quantity of, required by human beings, 

46. 
questions to Chapter II on, 107. 
rain-, 50. 

qualities of, 51. 
rssult of decomposition of organic im- 
purities in, 94. 
table of, 95. 
.'iver-, 51. 

objections to, 51. 

self-purification of, 52. 
salts in, 95. 
sediment in, 63. 

examination of, 63. 
snow-, 50. 
spring-, 54. 
storage and purification of, 77. 

by sedimentation, 81. 

filtration, 81. 

impurities from containers, lead pipes, 
78. 
sulphur in, 63. 



Water-supply, 494. 
for hospitals, 225. 
of ships. See Marine Hygiene, 
transparency of, 63. 
well, 61. 
artesian, analyses of, 62. 

quantity, 62. 
bacteria in, 61. 
Weather, influence on the causation of dis- 
ease and mortality, 17. 
Wells, artesian, 61. 

mineral contents of, 62. 
deep, 61. 
Wind, 6. 
dry, 6. 
moist, 6. 
Winds, mistral, bora, northers, sirocco, 
harmattan, simoon, fohn, 
16-17. . ir 
Wine, 142. 1? g 

adulteration of foreign, 142. 
Wharves, 489. 
Whisky, 142. 

Whitelegge's table showing periods of 
quarantine after contagious 
diseases, 242. 
Whooping cough, resume of, 441. 
Wool-sorters' disease, 260. 

Yeasts in air, 6. 

Yellow fever, history of, 423. 

in soldiers, 282. 

resume of, 441. 

vessels. See Quarantine. 

Zinc or copper vapors, poisoning by, 256. 





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